Fields on page 5
Youth Allowance or Centrelink Reference
Allowance or ABSTUDY Reference Number (if
ABSTUDY customer’s Number (if known)
known)
Family name
First given name
Second given name
Youth Allowance or ABSTUDY customer’s date
No
Yes
Give details below
Other name
Type of name (for example, name at birth)
Other name
Type of name (for example, name before marriage)
No
Yes
Yes
Date customer came into your care
Fields on page 6
current partner, back together
Married
Date married or last reconciled with your partner (DD MM YYYY)
Registered relationship
Date registered or last reconciled with your partner (DD MM YYYY)
De facto
not married or in a
Separated
de facto relationship)
Divorced
Date of divorce (DD MM YYYY)
Widowed
Date of partner’s death (DD MM YYYY)
Never married or lived
No
you a step parent of the
Yes
No
Yes
Fields on page 7
No
You do not need to
Yes
Mr
Mrs
Miss
Ms
Mx
Other
Family name
First given name
Second given name
Male
Female
Non-binary
Your date of birth (DD MM YYYY)
Your permanent address (if different to the Youth Allowance or ABSTUDY customer’s address)
ABSTUDY customer’s address)
Q12.PGDetails.Address3
Postcode
Your postal address (if different to above)
Your postal address (if different to above)
Q13.PGDetails.Address3
Postcode
Your contact phone number (including area code)
No
Yes
Mr
Mrs
Miss
Ms
Mx
Other
Family name
First given name
Second given name
Male
Female
Non-binary
Your date of birth (DD MM YYYY)
Your permanent address (if different to the Youth Allowance or ABSTUDY customer’s address)
ABSTUDY customer’s address)
Q12.PGPDetails.Address3
Postcode
Your postal address (if different to above)
Your postal address (if different to above)
Q13.PGPDetails.Address3
Postcode
Your contact phone number (including area code)
Fields on page 8
No
Yes
Name of payment(s)
Yes
No
Yes
No
BASE tax
Yes
No
Yes
If evidence is will use the child’s rate of
Date decrease occurred (DD MM YYYY)
Estimate the time the decrease will last
No
Yes
No
Yes
Yes
Fields on page 9
$
$
No
No
What is the approximate date your NOA will available for the BASE tax year? (DD MM YYYY)
Yes
I am not required to lodge an income tax return for the
Give a reason why.
No
What is the approximate date your NOA will available for the CURRENT tax year? (DD MM YYYY)
Yes
I am not required to lodge an income tax return for the
Give a reason why.
$
$
No
What is the approximate date your NOA will available for the BASE tax year? (DD MM YYYY)
Yes
I am not required to lodge an income tax return for the
Give a reason why.
No
What is the approximate date your NOA will available for the CURRENT tax year? (DD MM YYYY)
Yes
I am not required to lodge an income tax return for the
Give a reason why.
Fields on page 10
No
No
Yes
$
$
$
$
$
$
$
$
$
$
$
$
No
Yes
$
$
$
$
$
$
$
$
$
$
$
$
No
Yes
Yes
$
No
Yes
$
No
Yes
$
No
Yes
$
Fields on page 11
No
Yes
No
No
Youth
Yes
$
Date this started (DD MM YYYY)
No
dependent child. more information, read Notes.
Yes
No
Do you
Yes
No
Yes
No
$
Fields on page 12
Family name
First given name
Date of birth (DD MM YYYY)
YA / ABSTUDY / AIC
one of these
Family Tax Benefit, as
None of these payments, or claiming
No
No
Yes
No
Yes
Yes
Registered home schooling
Study outside Australia
No
Has this
Yes
Date completed (DD MM YYYY)
No
Is this
Yes
No
Yes
Yes
Name of School/College/Campus (including Australian Technical College, or education provider outside Australia)
Course title (for example, NSW Higher School Certificate or Certificate Level II in Hospitality or title of course outside Australia)
Date this child first enrolled or started Year 12 or equivalent qualification, whichever
Date this child complete Year 12 or equivalent
Full-time
Less than full-time
No
Yes
Yes
Has this child completed a Year 12 or equivalent qualification
Start date
Date this circumstance will cease
No
Yes
Fields on page 13
No
(for
Yes
Name
Address
Address
40C1.Address.2
Postcode
Phone number (including area code)
No
Yes
What is the percentage of this child
Date the current care arrangement started
Date these arrangements are expected to end
No
Do you
Yes
Fields on page 14
Family name
First given name
Date of birth (DD MM YYYY)
YA / ABSTUDY / AIC
Family Tax Benefit, as
None of these payments, or claiming
No
Yes
No
Yes
Registered home schooling
Study outside Australia
No
Yes
Date completed (DD MM YYYY)
No
Yes
No
Yes
Name of School/College/Campus (including Australian Technical College, or education provider outside Australia)
Course title (for example, NSW Higher School Certificate or Certificate Level II in Hospitality or title of course outside Australia)
Date this child first enrolled or started Year 12 or equivalent qualification, whichever
Date this child complete Year 12 or equivalent
Full-time
Less than full-time
No
Yes
Has this child completed a Year 12 or equivalent qualification
Start date
Date this circumstance will cease
No
Yes
Fields on page 15
No
Yes
Name
Address
Address
40C2.Address.2
Postcode
Phone number (including area code)
No
Yes
What is the percentage of this child
Date the current care arrangement started
Date these arrangements are expected to end
No
Yes
Fields on page 16
Family name
First given name
Date of birth (DD MM YYYY)
YA / ABSTUDY / AIC
Family Tax Benefit, as
None of these payments, or claiming
No
Yes
No
Yes
Registered home schooling
Study outside Australia
No
Yes
Date completed (DD MM YYYY)
No
Yes
No
Yes
Name of School/College/Campus (including Australian Technical College, or education provider outside Australia)
Course title (for example, NSW Higher School Certificate or Certificate Level II in Hospitality or title of course outside Australia)
Date this child first enrolled or started Year 12 or equivalent qualification, whichever
Date this child complete Year 12 or equivalent
Full-time
Less than full-time
No
Yes
Has this child completed a Year 12 or equivalent qualification
Start date
Date this circumstance will cease
No
Yes
Fields on page 17
No
Yes
Name
Address
Address
40C3.Address.2
Postcode
Phone number (including area code)
No
Yes
What is the percentage of this child
Date the current care arrangement started
Date these arrangements are expected to end
No
Yes
Fields on page 18
Family name
First given name
Date of birth (DD MM YYYY)
YA / ABSTUDY / AIC
Family Tax Benefit, as
None of these payments, or claiming
No
Yes
No
Yes
Registered home schooling
Study outside Australia
No
Yes
Date completed (DD MM YYYY)
No
Yes
No
Yes
Name of School/College/Campus (including Australian Technical College, or education provider outside Australia)
Course title (for example, NSW Higher School Certificate or Certificate Level II in Hospitality or title of course outside Australia)
Date this child first enrolled or started Year 12 or equivalent qualification, whichever
Date this child complete Year 12 or equivalent
Full-time
Less than full-time
No
Yes
Has this child completed a Year 12 or equivalent qualification
Start date
Date this circumstance will cease
No
Yes
Fields on page 19
No
Yes
Name
Address
Address
40C4.Address.2
Postcode
Phone number (including area code)
No
Yes
What is the percentage of this child
Date the current care arrangement started
Date these arrangements are expected to end
No
Yes
Fields on page 20
I authorise payment to go into
Payments are to go into
Name of bank, building society or credit union
Branch number (BSB)
Account number (this may not be your card number)
Account held in the name(s) of
No
Not sure
Yes
Go to next question
No
Yes
Your tax file number
Your tax file number
file number
ABSTUDY customers.
No
Yes
Your partner’s tax file
tax file number
file number
Your most recent statement or certificate that gives
Documents to support your decrease (or estimated
Your Notice of Assessment issued by the ATO
Your Australian Taxation Office income statement,
Dependent child details
Fields on page 21
49
Signature of Parent/Guardian
Date (DD MM YYYY)
Signature of Parent/Guardian Partner
Date (DD MM YYYY)
