Form SA296, Claim for a Commonwealth Seniors Health Card Completed Form Examples and Samples

Dear Assistance Team, I am writing to formally submit my application for the Commonwealth Seniors Health Card. My name is Arthur J. Miller, born on 12/04/1958. I currently live at 42 Banksia Street, Sunshine Coast, QLD 4567. My Centrelink CRN is 123-456-789-0. I am married to my wife, Margaret A. Miller (CRN 098-765-432-1), who is also applying for the card. We have lived in Australia all our lives and are both Australian citizens. Regarding our income, for the 2024/2025 financial year, my taxable income was $42,000, and Margaret’s was $38,500. We do not have any foreign income or rental losses. We do, however, receive income from an account-based income stream managed by Australian Super; the product reference number is AS-998877, and it commenced on 05/01/2023. I have not lodged an income tax return for this period because my only income was from a government pension/allowance. We both hold accounts with Westpac (BSB 034-001, Account 99887766). Please let us know if you need our tax file numbers; mine is 111-222-333 and Margaret’s is 444-555-666. We don't require an interpreter as we are fluent in English. We have never traveled outside Australia and have no dependent children living with us. We have authorized each other to act on our behalf. Best regards, Arthur Miller, dated 15 January 2026.