Fields on page 3
Your Customer
Customer Reference Number (if
Number (if known)
(if known)
Your family name
First given name
Second given name
Your date of birth (DD
date of birth (DD MM
birth (DD MM YYYY)
No
like further information visit one of our service worker. You can contact
Yes
No
Yes
No
Yes
No
Yes
Not sure
Give details below
All arrangements
Person permitted to enquire
Person permitted to update
Payment nominee
Correspondence nominee
Fields on page 4
No
Yes
Give details below
Phone number (including area code)
No
Yes
No
Yes
Give details below
Date your home
your home address
home address changed
Your new home address
Your new home address
9.Address3
Postcode
No
Yes
Give details below
Date your postal
your postal address
postal address changed
Your new postal address
Your new postal address
10.Address3
Postcode
No
Do you
Yes
You or your children are studying
Receiving medical treatment
Receiving care from a person in a
Receiving care in a nursing home
Providing care to a person in a
Overseas absence
Other
Give details below
Other
No
intend to
Yes
What was the date of
was the date of
the date of settlement
$
$
Expected date of home
date of purchase or
of purchase or completion of
No
includes the type of
Yes
Fields on page 5
park and pay site fees or live on a vessel
and pay mooring fees
townhouse, unit or flat
named in the trust deed
housing organisation.
supported accommodation or similar
disabilities
In an aged care home or nursing home
In a retirement village
to use for life
In accommodation where you pay no rent
you do not have a fixed address
Other, for example, this could be where you do not have a fixed address below
No
a
Yes
No
Yes
No
No
Not sure
Yes
Not sure
No
you live with the primary into account by the
Yes
No
means you are provided means the amount
Yes
No
No
$
Yes
$
$
$
On what date did you
what date did you start
did you start paying these fees
Fields on page 6
Boarding house, hostel, private hotel,
DummyCalcQ24
Private house, townhouse, unit or flat
Community housing
Defence housing
Caravan, cabin or mobile home
Boat
Other
Other
$
No
Yes
Your ex-partner’s family name
First given name
Second given name
Give details below
No
Yes
Other name(s)
No
Do you
Yes
No
No
Yes
Your ex-partner’s current address (if known)
Your ex-partner’s current address (if known)
31.Address3
Postcode
year. If you do not, details.
year. If you do not, it will details.
do not, it will take more time to
No
Yes
Give details below
When will you get back together
Fields on page 7
No
and legal adopted, step child
Yes
Full name
Age
When did you start this person (DD MM
did you start sharing person (DD MM YYYY)
you start sharing with (DD MM YYYY)
What is your relationship to this person
No
Yes
No
you and this person example, married,
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Fields on page 8
Full name
Address
Address
Q36.Address3
Postcode
Phone number (including area code)
Relationship to you
If you cannot give referee details, tell us why.
No
than 20
Yes
No
Yes
No
Yes
Fields on page 9
No
Yes
Give details below
Yes
No
Yes
Use the account details I have
A different account
acceptable. Do not include an
Tick this box if you would like all your payments
List the payment(s) to go into this account
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
List the payment(s) to go into this account
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
Fields on page 10
Copy of documents to verify the details of the sale
Relationship details – Separated under one roof
Relationship details (SS284) form
Details of each additional person who shares your
Details of your child’s care arrangements (FA012) form
Income and assets (Mod iA) form
Details of each additional person who shares your
Date (DD MM YYYY)
(DD MM YYYY)
YYYY)
Your signature (only required if returning by post or in person)
