Form SA474, Claim for an Australian Survivor Pension for a person living outside Australia Instructions
This form contains 104 fields organized into 29 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Assistance with Form Question | ||
| No | Checkbox |
Check this box if no one helped you fill in this form.
|
| Assisting Person | Text |
Please enter the name of the person who assisted you in filling out this form.
|
| Yes | Checkbox |
Check this box if someone helped you fill in this form.
|
| Assurance of Support | ||
| No | Checkbox |
Check this box if no one provided you with an Assurance of Support for your migration to Australia. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Not sure | Checkbox |
Check this box if you are not sure whether someone provided you with an Assurance of Support for your migration to Australia. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if someone did provide you with an Assurance of Support for your migration to Australia. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Australian Citizenship Status | ||
| No, not born in Australia | Checkbox |
Check this box if you are not an Australian citizen who was born in Australia, and be prepared to provide proof of your Australian residence status.
|
| Yes, born in Australia | Checkbox |
Check this box if you are an Australian citizen who was born in Australia, and proceed to question 19.
|
| Next Question Number | Number |
Please provide the number of the next question to proceed to based on your Australian citizenship status.
|
| Citizenship Details | ||
| Australia | Checkbox |
The user should check this box if Australia is their country of citizenship.
|
| Australian Citizenship Day | Text |
Enter the day of the month when your Australian citizenship was granted.
|
| Australian Citizenship Month and Year | Text |
Enter the month and year when your Australian citizenship was granted. Fill only if 'Australia' is 'Australia'.
Depends on:
Australia
|
| Other | Checkbox |
The user should check this box if their country of citizenship is not Australia and they need to provide details.
|
| Other Country of Citizenship | Text |
Enter the name of your other country of citizenship. Fill only if 'Other' is 'Other'.
Depends on:
Other
|
| Other Citizenship Grant Date | Date |
Provide the date when your other citizenship was granted. Fill only if 'Other' is 'Other'.
Depends on:
Other
|
| Contact Phone Number | ||
| Contact Phone Number | Text |
Please enter your contact phone number, including the area code.
|
| Country of Birth | ||
| Country of Birth | Text |
Provide the name of the country where you were born. Fill only if 'No, not born in Australia' is 'No'.
Depends on:
No, not born in Australia
|
| Customer Reference Number | ||
| Customer Reference Number Part 1 | Text |
Enter the first part of your Customer Reference Number.
|
| Customer Reference Number Part 2 | Text |
Enter the second part of your Customer Reference Number.
|
| Customer Reference Number Part 3 | Text |
Enter the third part of your Customer Reference Number.
|
| Customer Reference Number Part 4 | Text |
Enter the fourth part of your Customer Reference Number.
|
| Date of Birth | ||
| Date of Birth | Date |
Provide your date of birth.
|
| Date of Most Recent Start of Living in Australia | ||
| Select or enter the date in DD MM YYYY format | Text |
Depends on:
Yes
|
| Deceased Partner's Country of Residence | ||
| Australia | Checkbox |
Check this box if the deceased partner currently lives in Australia.
|
| Other | Checkbox |
Check this box if the deceased partner currently lives in a country other than Australia.
|
| Deceased Partner's Country of Residence | Text |
Please provide the country where your deceased partner was currently living, if it is not Australia.
|
| Deceased Partner's Country of Residence Additional Details | Text |
Please provide any additional details for your deceased partner's country of residence, if required. Fill only if 'Other' is 'Other'.
Depends on:
Other
|
| Deceased Partner's Name | ||
| Deceased Partner's Full Name | Text |
Provide the full name of your deceased partner. Fill only if 'Yes, Claiming from another country' is 'Yes'.
Depends on:
Yes, Claiming from another country
|
| Declaration Agreement | ||
| I have read, understood and agree to the above. | Checkbox |
Check this box to confirm that you have read, understood, and agree to the declaration statement provided above.
|
| First Country Lived In | ||
| Country Name | Text |
Enter the name of the first country you lived in. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Date Lived From | Date |
Enter the date you started living in this country. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Q22 | Text | |
| Form Return Date | ||
| Form Return Date | Date |
Provide the date by which this form should be returned.
|
| General | ||
| Instructions | Button | |
| Instructions | Button | |
| Q4GoToQ6 | Button | |
| Q8GoToQ19 | Button | |
| Q10GoToQ19 | Button | |
| Q11GoToQ20 | Button | |
| Q12GoToQ14.0 | Button | |
| Q12GoToQ14.1 | Button | |
| Q20GoToQ22 | Button | |
| Button | ||
| Clear | Button | |
| Helper Information | ||
| No | Checkbox |
Check this box if you do not give permission to contact the person who helped you complete this form.
|
| Yes | Checkbox |
Check this box if you give permission to contact the person who helped you complete this form.
|
| Permission Date | Date |
Enter the date permission was granted to contact the helper.
|
| Helper Name | Text |
Enter the full name of the person who helped you complete this form. Fill only if 'Yes', 'Yes' is 'Yes' for any.
Depends on:
Yes, Yes
|
| Helper Address Line 1 | Text |
Enter the first line of the helper's address. Fill only if 'Yes', 'Yes' is 'Yes' for any.
Depends on:
Yes, Yes
|
| Helper Address Line 2 | Text |
Enter the second line of the helper's address. Fill only if 'Yes', 'Yes' is 'Yes' for any.
Depends on:
Yes, Yes
|
| Helper Address Line 3 | Text |
Enter the third line of the helper's address. Fill only if 'Yes', 'Yes' is 'Yes' for any.
Depends on:
Yes, Yes
|
| Helper Postcode | Text |
Enter the postcode of the helper's address. Fill only if 'Yes', 'Yes' is 'Yes' for any.
Depends on:
Yes, Yes
|
| Helper Phone Number | Text |
Enter the helper's phone number, including the area code. Fill only if 'Yes', 'Yes' is 'Yes' for any.
Depends on:
Yes, Yes
|
| Lived Outside Australia Question | ||
| No | Checkbox |
Check this box if you have never lived outside Australia for any period. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if you have lived outside Australia for any period. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Country | Text |
Enter the name of a country you have lived in since birth, excluding Australia. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Pre-1965 Arrival Details | ||
| No | Checkbox |
Check this box if you did not start living in Australia before 1965. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if you started living in Australia before 1965 and need to provide further details. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Year of First Arrival | Text |
Enter the year you first started living in Australia. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Ship or Airline Name | Text |
Enter the name of the ship or airline on which you arrived in Australia. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Place of Arrival/Disembarkation | Text |
Enter the name of the place where you first arrived or disembarked in Australia. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Name at First Arrival | Text |
Enter the name you used when you first arrived in Australia. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Refugee or Humanitarian Visa Status | ||
| No | Checkbox |
Check this box if your partner or either of your parents did not arrive on a refugee or humanitarian visa. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if your partner or either of your parents arrived on a refugee or humanitarian visa. Fill only if 'Have you ever lived in Australia?' is 'Yes'.
Depends on:
Yes
|
| Residency History | ||
| No | Checkbox |
Check this box if you have never lived in Australia.
|
| DummyCalcQ11 | Text | |
| Yes | Checkbox |
Check this box if you have lived in Australia at any point in your life.
|
| Second Country Lived In | ||
| Second Country Name | Text |
Please enter the name of the second country where you have lived. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Date From Second Country | Date |
Please provide the date you started living in the second country. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Signature and Date | ||
| Signature | Text |
Please provide your signature in this field.
|
| Signature Date | Date |
Please enter the date your signature was provided.
|
| Survivor Pension Claim | ||
| No, Not claiming from another country | Checkbox |
Check this box if you are not claiming a Survivor Pension from a country other than Australia.
|
| Other Country Claim | Text |
Please enter the name of the country other than Australia from which you are claiming a Survivor Pension.
|
| Yes, Claiming from another country | Checkbox |
Check this box if you are claiming a Survivor Pension from a country other than Australia.
|
| Third Country Lived In | ||
| Third Country Name | Text |
Please enter the name of the third country you have lived in. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Country Date From | Date |
Please provide the date when you started living in the third country. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Travel History | ||
| No | Checkbox |
Check this box if you have not travelled outside Australia.
|
| Not applicable - Never travelled to Australia | Checkbox |
Check this box if you have never travelled outside Australia at any point in your life.
|
| Yes | Checkbox |
Check this box if you have travelled outside Australia, including short trips and holidays.
|
| DummyCalcQ7 | Text | |
| Year Last Entered Australia | Text |
Provide the year you last entered Australia. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Passport Number | Text |
Enter your passport number. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Passport Country of Issue | Text |
Enter the country where your passport was issued. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Visa Change Details | ||
| No | Checkbox |
Check this box if your visa has not changed since you arrived in Australia.
|
| Yes | Checkbox |
Check this box if your visa has changed since you arrived in Australia.
|
| Most Recent Visa Subclass (First) | Text |
Please provide the subclass for your most recent visa.
|
| Most Recent Visa Subclass (Second) | Text |
Please provide any additional subclass information for your most recent visa. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Date Most Recent Visa Granted | Date |
Please provide the date your most recent visa was granted. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Visa Details on Arrival | ||
| Visa Subclass | Text |
Please enter the subclass of your visa on arrival. Fill only if 'Permanent', 'Temporary' is 'Permanent' or is 'Temporary' any.
Depends on:
Permanent, Temporary
|
| Date Visa Granted | Date |
Please enter the date your visa was granted. Fill only if 'Permanent', 'Temporary' is 'Permanent' or is 'Temporary' any.
Depends on:
Permanent, Temporary
|
| Visa Type on Arrival | ||
| Permanent | Checkbox |
Check this box if you arrived on a permanent visa.
|
| Temporary | Checkbox |
Check this box if you arrived on a temporary visa.
|
| New Zealand passport (Special Category visa) | Checkbox |
Check this box if you arrived using a New Zealand passport, which grants a Special Category visa.
|
| Temporary Visa Details | Text |
Please provide additional details regarding the temporary visa type you arrived on.
|
| Not sure | Checkbox |
Check this box if you are unsure what type of visa you arrived on.
|
| Your Name | ||
| Mr | Checkbox |
Check this box if your title is 'Mr'.
|
| Mrs | Checkbox |
Check this box if your title is 'Mrs'.
|
| Miss | Checkbox |
Check this box if your title is 'Miss'.
|
| Ms | Checkbox |
Check this box if your title is 'Ms'.
|
| Mx | Checkbox |
Check this box if your title is 'Mx'.
|
| Other Title | Text |
Enter your title if it is not Mr, Mrs, Miss, Ms, or Mx. Fill only if 'Mx' is 'Other'.
Depends on:
Mx
|
| Family Name | Text |
Enter your family name (also known as last name or surname).
|
| First Given Name | Text |
Enter your first given name.
|
| Second Given Name | Text |
Enter your second given name.
|