Fields on page 1
Veteran
Given name(s)
Date of birth
File number (if known)
Partner
Given name(s)
Date of birth
File number (if known)
No
Yes
Fields on page 2
No
Yes
TPI/SRDP
Blind
Neither
No
Yes
Pension Bonus File Number
DVA
Centrelink
Both
When did you register
Mr
Mrs
Miss
Ms
Other
Family name
Given name(s)
Service number
Country of enlistment
Country of forces served in
Fields on page 3
No
Yes
List the other names
Type of name (e.g. maiden name)
List the other names
Type of name (e.g. maiden name)
Male
Female
No
Yes
Date of birth
(the address where you live)
(if same as home address,
Home telephone number
Mobile telephone number
Fax number
Work telephone number
Alternative telephone number
Fields on page 4
No
Yes
No
Yes
Type of payment
No
Yes
Number (CRN) on the card
No
Yes
Type of payment
$
$
application/grant
Regional Office
No
Yes
50
50
Date of marriage
50
together
50
from
to
indefinite
50
indefinite
50
Name of deceased partner
Date of partner’s death
50
Date of separation
Fields on page 5
Mr
Mrs
Miss
Ms
Other
Family name
Given name(s)
No
Yes
List the other names
Type of name (e.g. maiden name)
List the other names
Type of name (e.g. maiden name)
Male
Female
Male
No
Yes
72
POSTCODE
Home phone
No
Yes
No
Yes
Type of payment
No
Yes
Type of payment
No
Yes
Type of payment
$
$
84
Regional Office
Fields on page 6
No
Yes
number on the card
No
Yes
No
Yes
No
Yes
Pension Bonus File Number
Where did your partner register? DVA
Centrelink
Both
When did your partner register
Fields on page 7
No
Yes
Child’s full name
Date of birth
Male
Female
Is the child at school? Yes
No
Gross fortnightly income $
Child’s full name
Date of birth
Male
Female
Is the child at school? Yes
No
Gross fortnightly income $
Child’s full name
Date of birth
Male
Female
Is the child at school? Yes
No
Gross fortnightly income $
No
Yes
Child’s full name
Date of birth
Male
Female
Does the child receive No
Yes
Type of payment
Amount of payment $
$
Child’s full name
Date of birth
Male
Female
Does the child receive No
Yes
Type of payment
Amount of payment $
$
Child’s full name
Date of birth
Male
Female
Does the child receive No
Yes
Type of payment
Amount of payment $
$
Fields on page 8
No
Yes
No
Yes
An Australian citizen
An Australian citizen
The holder of a permanent visa
The holder of a permanent visa
The holder of a special purpose visa
The holder of a special purpose visa
The holder of a special category visa
The holder of a special category visa
A refugee or a former refugee
No
Yes
No
Yes
Yes
Yes
No
No
Country of birth
Country of birth
When did you first arrive in
When did your partner first arrive
How long have you
years
How long has your
years
Yes
Yes
No
No
No
Yes
No
Yes
Fields on page 9
No
Yes
Type of accommodation (from the list below)
In a home you (and/or your partner) own
In a home you (and/or your partner) own jointly
In a retirement village or independent living unit
In a residential aged care home (nursing home or
In a hospital or home for
In accommodation which you have the right
In private rental accommodation, caravan
In public housing
In a relocatable home
In a place where you pay private board and lodging
In free accommodation
In a home owned by a private trust
In a home owned by a private company
Other—please describe
156
Fields on page 10
On what date did you move into this accommodation
No
Yes
$
Amount $
per
Date you started paying
No
Yes
which provides nursing care
No
Yes
Amount $
per
Date you started paying
On what date did you move into this accommodation
No
Yes
organisation
Date paid/transferred
$
OR
$
Fields on page 11
Public housing
Private rent
Caravan park site fees
Relocatable home park site fees
Mooring fees
How much do you pay? $
per
pay? $
$
per
$
per
$
Name
Relationship to you
187
On what date did you move into this accommodation
Fields on page 12
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
For this claim
Their name
only, give their contact details
Phone number
For all future
Fields on page 13
My Tax File Number is
I do not have or do not know my Tax File Number
My partner’s Tax File Number is
My partner does not have or does not know their Tax
Fields on page 14
Name of bank, building society or credit union
Type of account (e.g. savings, cheque)
Branch where your account is held
Branch number (BSB)
Account number (this is not always the number
Account held in the name(s) of
To the same joint account the Veteran’s payment is made to
Name of bank, building society or credit union
Type of account (e.g. savings, cheque)
Branch where your partner’s account is held
Branch number (BSB)
Account number (this is not always the number
Account held in the name(s) of
Fields on page 15
Question 1
2
3
6
8
18
18
20
23
30
31
32
33
35
36
43
44
45
Fields on page 16
Question 47
48
50
51
52
53
54
