Fields on page 1
Claimant
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
Name of institution
Account Name(s) in which account is held term
Account number or held term deposit number Type of
Type of account
Current balance
Name of institution
Name(s) in which account is held term
held term deposit number Type of
Type of account
$
Text20
Text21
Text22
Text23
$
Text25
Text26
Text27
Text28
$
No
Yes
Amount owned by you
Amount owned by your partner
No
Yes
Name of company
Total Type of share
Total number of shares
You Partner
Partner
Name of company
Type of share
of shares
CB05
CB05a
Text39
Text40
Text41
CB06
CB06a
Text42
Text43
Text44
CB07
CB07a
Text45
Text46
Text47
CB08
CB08a
Fields on page 3
No
Yes
Money invested with
Certificate or Series Number Invested in
Invested in name(s) of
Current balance
Money invested with
Certificate or Series Number Invested in
Invested in name(s) of
Current balance
Text55
Text56
Text57
Text58
Text59
Text59b
Text60
Text61
No
Yes
Name of the person to whom the money is loaned
Date lent
Balance outstanding
You Partner
Partner
Name of the person to whom the money is loaned
Date lent
outstanding
CB12
CB12a
Text68
Date lent3
Text70
CB13
CB13a
No
Yes
Do NOT include superannuation or rollover
You Partner
Partner
investments. You will be asked about these
Check Box3
Check Box3a
Do NOT include bonds and debentures (you
Check Box4
Check Box4a
Text108
Check Box5
Check Box5a
Text109
Check Box6
Check Box6a
Fields on page 4
No
Yes
Name of institution/fund manager
Investment product
You Partner
Partner
Name of institution/fund manager
Investment product
Check Box9
Check Box9
Text114
Text115
Check Box10
Check Box10
Text116
Text117
Check Box11
Check Box11
No
Yes
Name of superannuation payment
Start date
Reference number
You Partner
Partner
Name of superannuation payment
Start date
Reference number
Check Box15
Check Box15
Text124
StartDate3
Text126
Check Box16
Check Box16
No
Yes
Name of product provider
Type of income stream Start date
Start date
Product reference number You
You Partner
Partner
Name of product provider
Type of income stream Start date
Start date
Product reference number You
Check Box19
Check Box19
Text135
Text136
StartDate6
Text138
Check Box20
Check Box20
Text139
Text140
StartDate7
Text142
Check Box21
Check Box21
Fields on page 5
No
Yes
No
Yes
No
Yes
No
Yes
What you gave away or sold for less than its value (e.g. money, car, second home, land, farm) Date given
farm) Date given or sold What it
sold What it was worth What you
What you got for it You
for it You Partner
Partner
value (e.g. money, car, second home, land, farm) Date given
farm) Date given or sold What it
sold What it was worth What you
What you got for it You
Check Box26
Check Box26a
Text151
DateGiven3
Text153
Text154
Check Box27
Check Box27a
money invested in, or do you receive income No
Yes
Type of investment
Current Name of organisation/company
Current value Income of investment in last 12
Income received Owned in last 12 months You
You Partner
Partner
Type of investment
Name of organisation/company
of investment in last 12
in last 12 months You
Check Box30
Check Box30a
No
Yes
No
Yes
Fields on page 6
No
Yes
Date ceased
No
Yes
Date ceased
No
Yes
and war pensions), benefits, allowances,
Country who pays it You
it You Partner
Partner
Type of payment
Country who pays it You
Check Box38
Check Box38
No
Yes
Name of boarder/lodger
Number of Relationship to you meals you (e.g. friend, nephew)provide
Number of you meals you each day each
Amount paid for board or lodging Date day each fortnight lodger
Date boarder or lodger started paying You
You Partner
Partner
Name of boarder/lodger
(e.g. friend, nephew)provide
each day each
day each fortnight lodger
lodger started paying You
Check Box41
Check Box41a
No
Yes
Type of payment
Text180
You Partner
Partner
Type of payment
Text182
Check Box44
Check Box44a
Fields on page 7
No
Yes
Make (e.g. Ford)
Model (e.g. Laser)
Year
Resale value
Amount owing You
You Partner
Partner
Make (e.g. Ford)
Model (e.g. Laser)
Year
Resale value
Amount owing You
Check Box47
Check Box47a
Text193
Text194
Text195
Text196
Text197
Check Box48
Check Box48a
Text198
Text199
Text200
Text201
Text202
Check Box49
Check Box49a
No
Yes
Name of insurance company
Policy number
Surrender value You
You Partner
Partner
Name of insurance company
Policy number
Surrender value You
Check Box52
Check Box52a
No
Yes
Current Description of asset
Current market value
Amount owing
You Partner
Partner
Description of asset
market value
Amount owing
Check Box55
Check Box55a
No
Yes
your (and your partner’s) household
Fields on page 8
No
Yes
No
Yes
No
Yes
You
Your partner
You and your partner
Temporarily
Text216
No
Yes
Permanently
Is the home you left
Check Box63
Check Box63
Check Box63
Check Box63
child)
$
What is the balance of the mortgage owing (if any)
What is the interest payable on the mortgage
No
Yes
Check Box63
Other—please specify
Fields on page 9
No
in with someone to provide care or to Yes
Provide care
Name of the person cared for
Be cared for
Name of the care provider
DateMovedIn
Long term or permanently
Short term or for respite care
When do you and/or your partner expect to leave
No
Yes
How much per fortnight
Partner pays
No
Yes
DOMESTIC
COMMERCIAL USE
No
Yes
Fields on page 10
No
Yes
Type of payment
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Fields on page 11
Question 1
3
5
6
7
8
9
10
12
13
14
15
17
22
26
27
28
29
30
31
33
34
34
35
36
Fields on page 12
Yes
No
on the claim form Part A
Another person
Their name
(including
Phone number