Fields on page 1
Claimant
Given name(s)
Date of birth
File number (if known)
Veteran
Given name(s)
Date of birth
File number (if known)
No
Yes
Fields on page 2
No
Yes
Pension Bonus File Number
DVA
Centrelink
Both
When did you register
No
Yes
Pension Bonus File Number
DVA
Centrelink
Both
Mr
Mrs
Miss
Ms
Other
Family name
Given name(s)
No
Yes
List the other names
Type of name (e.g. maiden name)
Male
Female
Male
Fields on page 3
No
Yes
(the address where you live)
(if same as home address, write
Home telephone number
Mobile telephone number
Fax number
Work telephone number
Alternative telephone number
No
Yes
Type of payment
No
Yes
Type of payment
No
Yes
Number (CRN) on the card
Fields on page 4
No
Yes
Type of payment
47
Number (CRN)
49
Regional Office
No
Yes
52
52
52
52
52
Date of marriage
55
from
to
indefinite
Name of deceased partner
Date of partner’s death
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
Male
Female
Male
74
POSTCODE
Home phone
No
Yes
Is the veteran receiving service No
Yes
Type of payment
No
Yes
Type of payment
No
Yes
83
No
Yes
Fields on page 6
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
Female
Male
Does the child receive No
Yes
Type of payment
Amount of payment
Other gross fortnightly income
Child’s full name
Date of birth
Male
Female
Does the child receive No
Yes
Type of payment
Amount of payment
Other gross fortnightly income
Child’s full name
Date of birth
Female
Male
Does the child receive No
Yes
Type of payment
Amount of payment
Other gross fortnightly income
Fields on page 7
An Australian citizen
The holder of a permanent visa
The holder of a special purpose visa
The holder of a special category visa
A refugee or a former refugee
No
Yes
No
Yes
Country of birth
130
131
No
Yes
No
Yes
Fields on page 8
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
In a hospital or home for people
In accommodation which you have the right
In private rental accommodation, caravan park
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
136
Fields on page 9
On what date did you move into this accommodation
No
Yes
How much
Amount $
per
Date you started paying
No
Yes
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
Amount paid
OR
Market value of
Fields on page 10
Public housing
Private rent
Caravan park site fees
Relocatable home park site fees
Mooring fees
How much do you pay
per
$
Amount paid for meals
per
Amount paid for lodging
per
$
Name
Relationship to you
172
On what date did you move into this accommodation
Fields on page 11
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 12
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
Fields on page 13
No
Yes
Yes
No
No
Yes
No
Yes
No
Yes
For this claim
For all future
Their name
only, give their contact details
Phone number
Fields on page 14
Question 2
5
7
8
17
17
27
28
29
34
35
36
38
39
43
44
45
46
