This form contains 50 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Address
Address Line 1	Text	Provide the first line of the street address, including unit number if applicable.
Address Line 2	Text	Provide the second line of the street address, if necessary.
Suburb or Town	Text	Enter the suburb or town of the address.
Postcode	Text	Enter the postcode for the address. Max length: 4 characters
Australian Business Number (ABN)
ABN Part 1	Text	Enter the first two digits of the Australian Business Number. Max length: 2 characters
ABN Part 2	Text	Enter the next three digits of the Australian Business Number. Max length: 3 characters
ABN Part 3	Text	Enter the next three digits of the Australian Business Number. Max length: 3 characters
ABN Part 4	Text	Enter the final three digits of the Australian Business Number. Max length: 3 characters
Claimant Distance
Claimant Distance/Hours Away	Number	Enter the current distance in kilometers or the number of hours the claimant is away from you. Max length: 4 characters
Customer Reference Number
Customer Reference Number Part 1	Text	Please enter the first part of your customer reference number. Max length: 3 characters
Customer Reference Number Part 2	Text	Please enter the second part of your customer reference number. Max length: 3 characters
Customer Reference Number Part 3	Text	Please enter the third part of your customer reference number. Max length: 3 characters
Customer Reference Number Part 4	Text	Please enter the fourth part of your customer reference number. Max length: 1 characters
Date
Day	Text	Enter the day of the date. Max length: 2 characters
Month	Text	Enter the month of the date. Max length: 2 characters
Year	Text	Enter the year of the date. Max length: 4 characters
Date of Birth
Day of Birth	Text	Please provide the day of your birth as a two-digit number. Max length: 2 characters
Month of Birth	Text	Please provide the month of your birth as a two-digit number. Max length: 2 characters
Year of Birth	Text	Please provide the full four-digit year of your birth. Max length: 4 characters
Full Name
Full Name	Text	Please provide the full legal name of the authorised referee.
General
Clear	Button
Information Sources
Personal knowledge	Checkbox	Check this box if you can confirm the claimant's information based on your personal knowledge.
Organisation records	Checkbox	Check this box if you can confirm the claimant's information from organisation records.
Council records	Checkbox	Check this box if you can confirm the claimant's information from council records.
School records	Checkbox	Check this box if you can confirm the claimant's information from school records.
Church records	Checkbox	Check this box if you can confirm the claimant's information from church records.
Medical records	Checkbox	Check this box if you can confirm the claimant's information from medical records.
Name
Family Name	Text	Please enter your family name as it appears on your official documents.
First Given Name	Text	Please enter your first given name as it appears on your official documents.
Second Given Name	Text	Please enter your second given name if applicable, as it appears on your official documents.
Name of Organisation or Department
Organisation or Department Name	Text	Please provide the full name of the organization or department.
Other Information Source Details
Other	Checkbox	Check this box if the claimant's information was confirmed from a source not listed, and provide details in the space below.
Other Source Type	Text	Specify the type of other information source used to confirm the claimant's information. Fill only if 'Other' is 'Yes'. Depends on: Other
Other Information Source Details	Text	Provide detailed information about the other source used to confirm the claimant's information. Fill only if 'Other' is 'Yes'. Depends on: Other
Other Names
No	Checkbox	Check this box if you have not been known by any other name(s) and wish to go to the next question.
Yes	Checkbox	Check this box if you have been known by any other name(s) and wish to provide details below.
DummyCalcQ4	Text
Other Name	Text	Please provide any other name by which you have been known, such as a name at birth, name before marriage, previous married name, alias, adoptive name, foster name, or Aboriginal/skin name. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Past Payment Recipient
Past Payment Recipient Name	Text	Provide the full name of the person who has received payment for you in the past, such as a parent, other relative, or guardian.
Phone Number
Phone Number	Text	Enter the phone number of the authorised referee, including the area code. Max length: 10 characters
Place of birth
Place of birth	Text	Enter the city, state, or country where the claimant was born.
Relationship with Claimant
Professionally	Checkbox	Check this box if you have known the claimant in a professional capacity.
Personally	Checkbox	Check this box if you have known the claimant in a personal capacity.
Years Known Claimant	Text	Please enter the number of years you have known the claimant, either professionally or personally. Fill only if 'Professionally', 'Personally' is 'Yes', any. Max length: 4 characters Depends on: Professionally, Personally
Signature
Sign	Text
Your Signature/Mark	Text	Please provide your signature or mark in this field.
Signature Date
Signature Day	Text	Please provide the day the form was signed. Max length: 2 characters
Signature Month	Text	Please provide the month the form was signed. Max length: 2 characters
Signature Year	Text	Please provide the year the form was signed. Max length: 4 characters
Title or Official Position
Title or Official Position	Text	Please provide the title or official position of the authorised referee.

Form SS241 - Referee's Report - Identification of a claimant Instructions