Fields on page 5
Your Customer
Customer Reference Number (if
Number (if known)
(if known)
Mr
Mrs
Miss
Ms
Mx
Other
Family name
First given name
Second given name
Your date of birth
date of birth (DD MM
birth (DD MM YYYY)
Your permanent address
Your permanent address
Q4.Address3
Postcode
Your postal address (if different to above)
Your postal address (if different to above)
Q5.Address3
Postcode
(including area code)
Mobile phone number
(including area code)
Email
Fields on page 6
give the date that you most with your partner.
Married
Date married or last with your partner (DD
married or last your partner (DD MM
or last reconciled (DD MM YYYY)
Registered relationship
is registered under
registered or last your partner (DD MM
or last reconciled (DD MM YYYY)
De facto
couple but you are
you started your last reconciled with your (DD MM YYYY)
your relationship with your MM YYYY)
Separated
marriage, registered or
of last separation MM YYYY)
separation
Divorced
Date of divorce (DD
of divorce (DD MM YYYY)
(DD MM YYYY)
Widowed
marriage, registered or
of partner’s death MM YYYY)
death
Never married or lived
No
Yes
Your partner’s Customer
partner’s Customer Reference
Reference Number (if
Number (if known)
Mr
Mrs
Miss
Ms
Mx
Other
Family name
First given name
Second given name
Date you started your relationship
partner’s date of birth
date of birth (DD MM YYYY)
Your partner’s permanent address (if different to your address)
Your partner’s permanent address (if different to your address)
Q12.Address3
Postcode
(including area code)
Mobile phone number
(including area code)
Email
Fields on page 7
14
Child’s family name
Child’s given name(s)
Child’s date of birth
date of birth (DD MM
of birth (DD MM YYYY)
Parent
Adoptive parent
Grandparent
Step-parent
Foster carer
Other
Give details below
Other
Parent
Adoptive parent
Grandparent
Step-parent
Foster carer
Other
Give details below
Other
No
Yes
No
No
Yes
No
Yes
Date the current care
the current care
care arrangement started
Date these (if applicable)
these arrangements are applicable)
arrangements are expected to end
No
you have a parenting plan,
Yes
Fields on page 8
No
Yes
No
No
for at least 14% of the more information, see pages 2–3.
Yes
Name
Address
Address
Q25 Details 0.Address3
Postcode
Phone number (including area code)
No
to ‘Information about
Yes
What percentage of care stated in question 22
What percentage of care of this child have during
Total number of nights
Total number of weeks
Total number of hours
Total number of nights
Total number of weeks
Total number of hours
alternate weekends from Friday 4:30 pm to Sunday 5 pm or half of the Christmas school holidays.
No
someone
Yes
Fields on page 9
Child’s family name
Child’s given name(s)
Child’s date of birth
date of birth (DD MM
of birth (DD MM YYYY)
Parent
Adoptive parent
Grandparent
Step-parent
Foster carer
Other
Give details below
Other
Parent
Adoptive parent
Grandparent
Step-parent
Foster carer
Other
Give details below
Other
No
Yes
No
No
Yes
No
Yes
Date the current care
the current care
care arrangement started
Date these (if applicable)
these arrangements are applicable)
arrangements are expected to end
No
you have a parenting plan,
Yes
Fields on page 10
No
Yes
No
No
for at least 14% of the more information, see
Yes
Name
Address
Address
Q25 Details 1.Address3
Postcode
Phone number (including area code)
No
to ‘Information about
Yes
What percentage of care stated in question 22
What percentage of care of this child have during
Total number of nights
Total number of weeks
Total number of hours
Total number of nights
Total number of weeks
Total number of hours
alternate weekends from Friday 4:30 pm to Sunday 5 pm or half of the Christmas school holidays.
No
Yes
Fields on page 11
No
Yes
• any concerns you may have (for example, contacting the other parent, carer or guardian).
35
Your signature
Date (DD MM YYYY)
(DD MM YYYY)
YYYY)
Fields on page 12
Other carer’s name
Other carer’s signature
Date (DD MM YYYY)
(DD MM YYYY)
YYYY)
Give your best office hours contact phone number, verify your agreement to the care arrangements (including area code)
