SU599 Assurer's statement to Centrelink Instructions
This form contains 86 fields organized into 30 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Assistance Given Details | ||
| Assistance Type | Text |
Provide a brief description of the type of assistance given to the person.
|
| Assistance Details | Text |
Provide further details about the assistance given, including the amount and any other relevant information. Fill only if 'Yes, assistance given' is 'Yes'.
Depends on:
Yes, assistance given
|
| Assistance Given Status | ||
| No assistance given | Checkbox |
Check this box if you are not giving any financial or other form of assistance to the person you signed an assurance of support for.
|
| Yes, assistance given | Checkbox |
Check this box if you are giving financial or other form of assistance to the person you signed an assurance of support for and need to provide details.
|
| Assistance Willingness Details | ||
| Willing Assistance Amount | Number |
Enter the amount of assistance you are willing to provide.
|
| Willing Assistance Details | Text |
Provide details about the type and amount of assistance you are willing to provide. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Assistance Willingness Status | ||
| No | Checkbox |
Check this box if you are not willing to provide assistance and support to the person you signed an assurance of support for.
|
| Yes | Checkbox |
Check this box if you are willing to provide assistance and support to the person you signed an assurance of support for.
|
| Assuree's Customer Reference Number | ||
| Reference Number Segment 1 | Text |
Please enter the first segment of the assuree's customer reference number.
|
| Reference Number Segment 2 | Text |
Please enter the second segment of the assuree's customer reference number.
|
| Reference Number Segment 3 | Text |
Please enter the third segment of the assuree's customer reference number.
|
| Reference Number Segment 4 | Text |
Please enter the fourth segment of the assuree's customer reference number.
|
| Assuree's Date of Birth | ||
| Date of Birth | Date |
Please provide the assuree's date of birth.
|
| Assuree's Name | ||
| Family Name | Text |
Please enter the assuree's family name.
|
| First Name | Text |
Please enter the assuree's first name.
|
| Second Given Name | Text |
Please enter the assuree's second given name.
|
| Declaration | ||
| Signature | Text |
Please provide your signature to confirm the declaration.
|
| Date of Declaration | Date |
Please enter the date when the declaration was signed.
|
| Employment Details | ||
| No | Checkbox |
The user should check this box if they are not currently employed.
|
| Yes | Checkbox |
The user should check this box if they are currently employed.
|
| Employment Details Reference | Text |
Please enter any reference number or identifier related to the employment details being provided.
|
| Weekly Earnings Before Tax | Number |
Please enter your total gross weekly earnings before any taxes or deductions. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Employer Name | Text |
Please enter the full legal name of your employer. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Employer Address Line 1 | Text |
Please enter the first line of your employer's street address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Employer Address Line 2 | Text |
Please enter the second line of your employer's street address, if applicable. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Employer Address Line 3 | Text |
Please enter the third line of your employer's street address, if applicable. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Employer Postcode | Text |
Please enter the postcode or zip code for your employer's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| First Financial Institution Account | ||
| Financial Institution Name | Text |
Please enter the full name of the financial institution where this account is held.
|
| Account Balance | Number |
Please enter the current balance of this financial account.
|
| First Income Source Details | ||
| First Income Source | Text |
Please enter the source from which you receive or are entitled to receive your first income. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| First Weekly Amount Before Tax | Number |
Please provide the weekly amount of your first income source before tax. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fourth Financial Institution Account | ||
| Institution Name | Text |
Provide the full name of the fourth financial institution.
|
| Account Balance | Number |
Enter the current balance of the fourth financial institution account.
|
| Fourth Income Source Details | ||
| Fourth Source of Income | Text |
Please provide details about the fourth source of income. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fourth Weekly Amount Before Tax | Number |
Enter the weekly amount of the fourth income source before tax. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| General | ||
| Instructions button | Button | |
| Q8.PostalAddress1 | Text | |
| Q8.PostalAddress2 | Text | |
| Q11GoToQ13 | Button | |
| Q16GoToQ19 | Button | |
| Q17GoToQ19 | Button | |
| Button | ||
| Clear | Button | |
| Other Government Payment Details | ||
| No | Checkbox |
Check this box if you do not currently receive, and have not recently applied for, a payment from the government or any other government department.
|
| Yes | Checkbox |
Check this box if you currently receive, or have recently applied for, a payment from the government or any other government department.
|
| Other Government Department Details | Text |
Provide additional details regarding the government department that issued the payment, if applicable.
|
| Type of Payment | Text |
Enter the specific type of payment received from the government department. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Amount Per Fortnight | Number |
Enter the amount of payment received per fortnight. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Income Status | ||
| No | Checkbox |
Check this box if you do not receive, or are not entitled to receive, any income from other sources.
|
| Yes | Checkbox |
Check this box if you receive, or are entitled to receive, any income from other sources.
|
| Source of Income | Text |
Please specify the origin or type of other income you receive.
|
| Privacy notice | ||
| Q19 | Text | |
| Property Income Details | ||
| No | Checkbox |
Check this box if you do not receive income from property that is rented or leased.
|
| DummyCalcQ11 | Text | |
| Yes | Checkbox |
Check this box if you receive income from property that is rented or leased.
|
| Gross Weekly Rent | Number |
Please provide the gross weekly income received from rented or leased property. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Property Mortgage Details | ||
| No | Checkbox |
Check this box if the property is not mortgaged.
|
| Yes | Checkbox |
Check this box if the property is mortgaged and you need to provide details.
|
| Number of Mortgage Details | Number |
Please provide the number of mortgage details being provided.
|
| Amount Owing | Number |
Please specify the total amount currently owing on the property mortgage. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Interest Rate | Number |
Please provide the annual interest rate of the property mortgage. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reason for Not Providing Assistance | ||
| Reason for Not Providing Assistance | Text |
Provide a detailed explanation of why you are not willing to provide assistance and support. Fill only if 'No' is 'No'.
Depends on:
No
|
| Second Financial Institution Account | ||
| Second Institution Name | Text |
Enter the name of the second financial institution.
|
| Second Account Balance | Number |
Enter the current balance of the second financial institution account.
|
| Second Income Source Details | ||
| Second Source of Income | Text |
Please provide the type or origin of your second income source. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Weekly Amount Before Tax | Number |
Please enter the weekly amount of your second income source before tax. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Financial Institution Account | ||
| Third Financial Institution Name | Text |
Enter the name of the third financial institution.
|
| Third Financial Institution Balance | Number |
Enter the balance of the account for the third financial institution.
|
| Third Income Source Details | ||
| Third Source of Income | Text |
Please provide the name or description of the third source of income. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Source Weekly Amount Before Tax | Number |
Please provide the weekly amount of income before tax for the third source. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Your Contact Phone Number | ||
| Contact Phone Number | Text |
Please provide your contact phone number.
|
| Your Customer Reference Number | ||
| Customer Reference Number Part 1 | Text |
Please provide the first part of your customer reference number.
|
| Customer Reference Number Part 2 | Text |
Please provide the second part of your customer reference number.
|
| Customer Reference Number Part 3 | Text |
Please provide the third part of your customer reference number.
|
| Customer Reference Number Part 4 | Text |
Please provide the fourth and final part of your customer reference number.
|
| Your Date of Birth | ||
| Day of Birth | Date |
Provide the day of your birth.
|
| Your Name | ||
| Family Name | Text |
Please enter your family name as it appears on official documents.
|
| First Given Name | Text |
Please enter your first given name as it appears on official documents.
|
| Second Given Name | Text |
Please enter your second given name as it appears on official documents.
|
| Your Permanent Address | ||
| Address Line 1 | Text |
Please provide the first line of your permanent address.
|
| Address Line 2 | Text |
Please provide the second line of your permanent address.
|
| Address Line 3 | Text |
Please provide the third line of your permanent address, typically including suburb, city, or state.
|
| Postcode | Text |
Please enter your permanent address postcode.
|
| Your Postal Address | ||
| Address Line 1 | Text |
Please enter the first line of your postal address.
|
| Address Line 2 | Text |
Please enter the second line of your postal address, including city or town.
|
| Postcode | Text |
Please enter your postal code.
|