EM091.150227
Disaster Recovery Allowance
Tropical Cyclone Marcia (Qld) February 2015
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Your Centrelink Reference Number (if known) Do you have a Centrelink Reference Number?
4
No Yes
Go to next question
You may not be eligible for this assistance.
Please call us on 180 22 66.
Are you receiving an income support payment or pension (e.g. Age Pension, Newstart Allowance, Service Pension from the Department of Veterans’ Affairs or Farm Household Allowance)?
5
No Yes
Do any of the following apply to you?
6
Go to next question A permanent visa holder
Tick the first option that applies to you
Go to next question A New Zealand passport holder
Go to next question Holder of an
eligible temporary visa
None of the above You may not be eligible for this assistance.
Please call us on 180 22 66.
Refer to the factsheet for a list of eligible temporary visa classes.
Do any of the following apply to you?
7
Tick ALL that apply Suburb Live in an affected area
None of the above You may not be eligible for this assistance.
Please call us on 180 22 66.
Suburb Work in the affected area
Suburb Derive income from the
affected area
Have you lost or suffered a reduction in your income as a direct result of the disaster?
8
Go to next question
You may not be eligible for this assistance.
Please call us on 180 22 66.
No Yes
Are you 22 years of age or older?
9
Go to next question No
Yes Go to 14
Please read this before answering the following questions.
Questions 10–13 are to be completed ONLY if you are under 22 years of age.
Are you a parent or have a dependent child in your care?
10
Go to next question No
Yes Go to 14 Do you need an interpreter when dealing with us?
1
Go to 3 No
Yes Go to next question
This includes an interpreter for people who have a hearing or speech impairment.
To speak to us in languages other than English, call 131 202.
What is your preferred spoken language?
2
What is your preferred written language?
3
Go to next question An Australian citizen
CLK0EM091 150227
Your name
Other Family name
14
First given name
Second given name
Ms Miss
Mrs Mr
What was your place of residence at the time of the disaster?
Postcode
What is the address of your current residence?
(if different to above)
Postcode
Your date of birth
17
/ /
Go to next question No
Have you ever used or been known by any other name (e.g. name at birth, maiden name, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name)?
15
Other name
Type of name (e.g. name at birth) Give details below
If you have more than 1 other name, attach a separate sheet with details.
Yes
What is your estimated income for the current financial year?
11
$
Are you wholly or substantially dependent on another person?
12
No Yes
Refer to the factsheet for an explanation of ‘wholly or substantially dependent’.
Are you currently living with your parent(s) or guardian(s)?
13
No Yes
Your sex
16
Male Female
18
Is this a temporary residence? No Yes
Postal address (if different to above)
Postcode
Phone number ( )
Mobile phone number
Note: This mobile number will automatically be subscribed to our electronic messaging service. We may use this mobile number to contact you. For Terms and Conditions, go to our website www.humanservices.gov.au/em
To help us serve you better, please provide your mobile number How can we contact you?
21 19
20
Were you in Australia when the disaster occurred?
22
Go to next question No
Go to 24 Yes
When did you return to Australia after the disaster?
23
/ /
IMPORTANT
This payment can be paid for a maximum period of 13 weeks dependent on your circumstances. Before the end of the 13 weeks we will contact you to advise of the required steps that must be taken if you require further assistance. Please ensure your contact details are always up to date.
EM091.150227
Your visa details on arrival
30
Date visa granted Visa sub class
/ /
Are you living in Australia permanently?
24
No Yes
Please read this before answering the following questions.
‘Permanently’ means you normally live in Australia on a long-term basis. Holidays or short trips outside Australia would not affect this.
Australia
Are you an Australian citizen who was born in Australia?
26
Country of citizenship Other
No
Yes Go to 32
What is your country of citizenship?
28
Date you became an Australian citizen
/ /
What is your current type of visa?
29
Permanent Go to next question Temporary Go to next question Unknown (e.g. arrived
on parent’s passport)
Go to 31
Are you subject to an Assurance of Support agreement?
31
Go to next question No
Yes What is the name of your Assurer?
You will need to provide proof of your Australian residence status (e.g. citizenship papers, passport or other documentation).
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Go to 31
New Zealand passport (special category visa)
Go to 32
Except for short trips or holidays, have you EVER lived outside Australia?
32
Go to next question No
Yes If you were born outside Australia, include the country where you were born.
Include the period(s) you have lived in each country.
Do NOT include short trips or holidays.
Country of residence
1
From / / To / /
Country of residence
2
From / / To / /
If you require more space, attach a separate sheet with details.
Do you have a partner?
33
Go to 42 No
Yes Go to next question
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Your partner’s Centrelink Reference Number (if known) Does your partner have a Centrelink Reference Number?
34
No Yes
Your partner’s name
Other Family name
35
First given name
Second given name
Ms Miss
Mrs Mr
Have you lived or travelled outside Australia since 1 September 1994, including short trips and holidays?
25
The answer to this question may enable Human Services to access electronic records held by Australia’s immigration department and help verify your Australian residence.
Go to next question No
Yes Give details below Passport number
Country of issue
What is your country of birth?
27
Child’s family name
Child’s given names
Child’s date of birth
/ /
Child’s sex
Male Female
Other name this child has been known by
Are you the principal carer of this child?
43
Give details below of your youngest dependent childIs there a shared care arrangement in relation to this child?
No Yes What is your percentage of shared care?
%
44
Provide details of your usual work (e.g. employment, self-employment, sub-contracting, farming).Employer’s name, business name or farm name
Australian Business Number (ABN)
Address
Postcode Phone number
( )
What industry are you employed in?
For example:
a banana industry should write: Agriculture – banana industry a clothes shop assistant should write: Retail – clothes.
Is this work
Other Give details Do you have dependent children under 16 years of age in your
care?
42
Go to 44 No
Yes Go to next question
Note: There are no additional payments for dependent children. If you currently receive Family Tax Benefit you may need to revise your income estimate.
Do you give permission for your partner to discuss details about your claim?
No Yes
41
Your partner’s date of birth
38
/ /
Go to next question No
Has your partner ever used or been known by any other name (e.g. name at birth, maiden name, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name)?
36
Other name
Type of name (e.g. name at birth) Give details below
If your partner has more than 1 other name, attach a separate sheet with details.
Yes
Your partner’s sex
37
Male Female
Does your partner live at the same ‘residential address’ as you?
39
Go to next question No
Yes Go to 41
Your partner’s residential address
Postcode
40
If you have more than one employer, attach a separate sheet with details.
You must answer questions 44 to 53 for each employer.
Was your income from this employer impacted as a result of the disaster?
No Yes
No Yes
Do you receive Family Tax Benefit for this child?
No Yes
Seasonal Part-time
Full-time Casual
EM091.150227
46
What date did you stop working or first incur a reduction in your income as a result of the disaster?/ /
47
Which one of the following reasons best describes why you have suffered a loss of income?Workplace damaged or destroyed I am unable to get to my usual workplace Cancelled bookings/orders
Cancellation of planned tourism events Loss and/or damage to stock
Injury suffered
Loss and/or damage of machinery/tools Loss of necessary utilities
Lack of staff/workers/contractors Unable to import/export products Other
48
Explain why you stopped work in further detailNote: If you did not stop working as a result of the disaster you may not be eligible for this assistance.
49
Are you on planned leave from your workplace?Go to next question No
Yes
Go to 53
50
What type of leave?For example: annual leave, sick leave, maternity.
51
Start date of leave period/ /
End date of leave period
/ /
52
Is this paid leave?No Yes
53
Have you returned to work after the disaster?Date you returned to work after the disaster No
Yes
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/ /
54
Do you have an income protection policy?Name of insurance company No
Yes
Go to 58
55
Have you lodged a claim or intend to lodge a claim for the loss of income?Go to 57 No
Yes
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56
Explain why you have not lodged a claimGo to 58
57
What was the outcome of the claim?Pending decision Rejected To be lodged in future
Granted Give details below Has a waiting period been applied?
Waiting period end date No
Yes
/ /
Have payments commenced?
Attach a copy of the most recent letter or statement from the insurance policy provider showing payment details.
No Yes
58
Do you have an interest in any real estate in and/or outside Australia (other than your principal place of residence)?Go to next question No
Yes
Go to 60 Are you self-employed?
No Yes
45
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The income you receive from self-employment must be included at question 65 and question 69.
Any income you receive from this insurance policy must be included at question 69.
59
Do you receive an income from the properties (i.e. rental/lease income)?No Yes
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Attach a copy of your tax return for the previous year when lodging this claim.
The income you receive from rental properties must be included at question 65 and question 69.
60
Do you own any shares, options, rights, convertible notes or other securities LISTED on an Australian Stock Exchange (e.g. ASX, NSX, APX or Chi-X) or a stock exchange outside Australia?Include shares traded in exempt stock markets.
Do NOT include:
• managed investments
• investments purchased with a margin loan.
No Yes
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Attach the latest statement for each share holding.
Name of company
1
Country if not Australia
Security code (if known)
Your share
% Number of shares or
other securities
The income you receive from these investments must be included at question 65 and question 69.
If you have more than 1 investment, attach a separate sheet with details.
61
Do you own any shares, options or rights in PUBLIC companies NOT Listed on a stock exchange?Do NOT include:
• managed investments
• investments purchased with a margin loan.
No Yes
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Attach the latest statement detailing your share holding for each company (if available).
Name of company
1
Current market value Number of shares, options or rights
Your share
%
Type of shares, options or rights
The income you receive from these investments must be included at question 65 and question 69.
If you have more than 1 investment, attach a separate sheet with details.
$
EM091.150227
Please read this before answering the following question.
63
An income stream product is a regular series of payments which may be made for a lifetime or a fixed period by:
• a financial institution
• a retirement savings account
• a superannuation fund
• a Self Managed Superannuation Fund (SMSF)
• a Small APRA Fund (SAF).
Types of income streams include:
• account-based pension (also known as allocated pension)
• market-linked pension (also known as term allocated pension)
• annuities
• defined benefit pension (e.g. ComSuper pension, State Super pension)
• superannuation pension (non-defined benefit).
Do you receive income from any income stream products?
Give details below No
Yes
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Name of product provider/SMSF/SAF
1
Type of income stream
Product reference number Your share
%
You will need to obtain a schedule from your product provider for each income stream product.
The income you receive from income stream products must be included at question 65 and question 69.
If you have more than 1 income stream, attach a separate sheet with details.
62
Do you have any managed investments in and/or outside Australia?No Yes
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Attach a document which gives details (e.g. certificate with number of units or account balance) for each investment.
The income you receive from these investments must be included at question 65 and question 69.
Include:
• investment trusts
• personal investment plans
• life insurance bonds
• friendly society bonds.
Do NOT include:
• conventional life insurance policies
• investments purchased with a margin loan.
APIR code – is commonly used by fund managers to identify individual financial products.
If you have more than 1 managed investment, attach a separate sheet with details.
Name of company
1
Name of product (e.g. investment trust)
Type of product/option (e.g. balanced, growth)
APIR code (if known) Number of units
Current market value Currency if not AUD
$
Your share %
Give details below
65
What was your gross income for the 8 weeks immediately before the disaster?Gross income is the amount of income you earn before any deductions are taken out (e.g. tax).
Include income from all sources, this includes income from employment, income protection policies, shares, investments, real estate income, superannuation, self-employment, holiday pay, commission work etc.
Source of income Amount
$
$ Total for 8 week period
$
$
Attach verification documents to confirm your income (e.g. payslips, tax returns, BAS statements or a letter from your employer).
If you have more than 7 sources of income, attach a separate sheet with details.
Do you have any money invested in, or do you receive income from, any other investments or sources, not declared elsewhere on this form?
64
Type of investment/income
Name of organisation/company
Currency if not AUD Include:
• all investments from outside Australia (including superannuation) not declared elsewhere on this form.
Do NOT include:
• income from real estate in or outside Australia, private trusts, private companies or business
• social security payments
• an account used exclusively for funding from the National Disability Insurance Scheme.
Give details below No
Yes
Go to next question
Your share
%
1
If you have more than 1 other investment or source of income, attach a separate sheet with details.
The income you receive from these investments or sources must be included at question 65 and question 69.
You will need to provide proof of your income from other investments and sources.
$
$
$
$
66
If the disaster had not occurred, would your income have continued at the same fortnightly amount in the 13 weeks following your loss of income as it was before the disaster?Go to 69 No
Yes
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67
Did you expect your income to:Decrease Increase
68
How much did you expect to earn each fortnight on average for the 13 weeks after the disaster?$
You will only need to provide proof of the expected increase in income (e.g. contract documents).
Tick ONE only
per fortnight
EM091.150227
Do you have any accounts in banks, building societies, credit unions or church and charitable development funds?
70
Name of bank, building society or credit union
Type of account
Account number (this may not be your card number) Branch number (BSB)
69
In the 14 days following your loss of income, did you receive, or are you entitled to receive, any income from any source?Source of income Amount
$
$ Total
$
$
You will need to provide proof of your income.
If you have more than 5 sources of income, attach a separate sheet with details.
Give details below No
Yes
Go to next question
Give details below No
Yes
Go to next question
Balance
$
Your share
%
1
If you have more than 2 accounts, attach a separate sheet with details.
Do you have any cash?
71
How much cash do you have?
No Yes
Go to next question
$
Name of bank, building society or credit union
Type of account
Account number (this may not be your card number) Branch number (BSB)
Balance
$
Your share
%
2
Do NOT include
• an account used exclusively for funding from the National Disability Insurance Scheme
• bank accounts held in trust, or
• private companies.
$
$
Gross income is the amount of income you earn before any deductions are taken out (e.g. tax).
Include income from employment, income protection policies, shares, investments, real estate income, superannuation, self-employment, holiday pay, commission work etc.
Where do you want your payment made?
75
Name of bank, building society or credit union Branch where your account is held
Account number (this may not be your card number) Branch number (BSB)
Account held in the name(s) of Your tax file number
72
Please read this before answering the following questions.You are not breaking the law if you do not give us your tax file number, but if you do not provide it to us, or authorise us to get it from the Australian Taxation Office, you may not be paid.
In giving us your tax file number in relation to this claim you authorise us to use your tax file number for other social security payments and services in future where necessary.
Do you want tax taken out of your payment?
No Yes
Go to next question
Amount
(must be in whole dollars)
$ .00 per payment OR
Percentage (%) of taxable payment
% per payment Enter the amount OR percentage of tax you want taken out from each payment.
The bank, building society or credit union account must be in your name. A joint account is acceptable.
I do not have a bank, building society or credit union account
We will contact you to discuss
Go to next question The account nominated below
Would you like a Centrelink social worker to contact you?
76
What number would you like to be contacted on?
No Yes
Go to next question
( )
Please tick what information has been provided with the claim.
If verification documentation is not provided with this claim it will need to be provided within 14 days.
Checklist
77
All questions on this claim have been completed Proof of identity that add up to the value of 50 points (refer to the factsheet for acceptable forms and point value of documents) Passport or visa details (if not an Australian citizen) (if you answered No at question 26)
Proof of income before the disaster (if required at question 65)
Proof of income for the 14 days following your loss of income (if you answered Yes at question 69) Copy of your tax return for the previous year (if you answered Yes at question 59) The latest statement or document for each investment (if you answered Yes at question 60, 61 or 62) A schedule from your product provider for each income stream (if you answered Yes at question 63) Proof of income from investments or other sources (if you answered Yes at question 64) Go to next question
No Not sure
Go to next question
Have you given us your tax file number before?
Go to 74 Yes
73
Do you have a tax file number?No Yes
Please call us on 180 22 66.
74
Please read this before answering the following question.Disaster Recovery Allowance is a taxable payment. If your only income for this financial year is the payment you are now claiming, you may not have to pay any tax.
However, you may have to pay tax if you get any other income this financial year, such as salary or wages.
If you think you will have to pay tax this year, you can ask us to deduct tax instalments from your payment. You can change this at any time.
If you are not sure how much tax to have taken out of your payment, contact the Australian Taxation Office.
Proof of expected increased income (if required at question 68)
EM091.150227
I declare that:
• the information I have provided in this form is complete and correct.
• I have read the privacy notice above.
I understand that:
• giving false or misleading information is a serious offence.
• the Australian Government Department of Human Services can make relevant enquiries to make sure I receive the correct entitlement.
• the Australian Government Department of Human Services may request evidence to support any claims made on this form.
• I must tell the Australian Government Department of Human Services of any changes to this information within 14 days.
• any overpayment will be recovered.
Statement
Date
/ /
Office Use only
CSO Logon ID
POI type
Serial number
State of issue Country of issue
Issue date
/ /
Expiry date
/ /
Original document sighted and returned POI type
Serial number
State of issue Country of issue
Issue date
/ /
Expiry date
/ /
POI type
Serial number
State of issue Country of issue
Issue date
/ /
Expiry date
/ /
POI type
Serial number
State of issue Country of issue
Issue date
/ /
Expiry date
/ /
79
Your signature
Privacy and your personal information
Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services.
This information is required to process your application or claim.
Human Services may disclose your information to Commonwealth departments, other persons, bodies or agencies ONLY where you have provided consent or it is required or authorised by law.
Human Services may disclose limited personal information about you to individuals when your circumstances affect their entitlement to payments and services. Your information may be disclosed to the Attorney-General’s Department, the Department of Immigration and Border Protection and their service providers, or as authorised or required by law. Relevant information may be given to Australian and State Government Departments and Agencies who are involved in the joint administration of this disaster.
Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law.
You can get more information including our privacy policy at www.
humanservices.gov.au/privacy or by requesting a copy from the department.
