Fields on page 3
Your Customer
Customer Reference Number
Number (if known)
(if known)
Your name Family name
First given name
Second given name
Your date of birth
date of birth (DD MM
of birth (DD MM YYYY)
No
Do you
Yes
Your partner’s
partner’s Customer Reference
Reference Number (if
Number (if
Your partner’s name Family name
First given name
Second given name
Your partner’s date
partner’s date of birth
date of birth (DD MM YYYY)
No
not include
Yes
You
Your partner
Employer’s name
Address
Address
Q8.Address3 1
Postcode
Phone number (including area code)
Australian
Business Number
Number (ABN)
(ABN)
Full-time
Part-time
Seasonal
Casual
clock-card number
Q8.HoursWorked1
per fortnight (before tax $
No
Yes
Fields on page 4
You
Your partner
Employer’s name
Address
Address
Q8.Address3 2
Postcode
Phone number (including area code)
Australian
Business Number
Number (ABN)
(ABN)
Full-time
Part-time
Seasonal
Casual
clock-card number
Q8.HoursWorked2
$
No
Yes
No
Yes
No
Disability Support Pension Pension Blind if claiming
Yes
No
any
Yes
No
Parenting Payment
Yes
Fields on page 5
No
Yes
DummyCalcQ13
Employer or business name
Australian
Business Number
Number (ABN)
(ABN)
Who works for this employer? You
Your partner
Employer or business name
Australian
Business Number
Number (ABN)
(ABN)
Who works for this employer? You
Your partner
No
Yes
Continued
Type of leave entitlement payment
$
Number of working days covered by the payment
Q14.DatePaid Payable.1.D
Q14.DatePaid Payable.1.M
by the payment
You
Your partner
Employer’s details Name of business
Australian
Business Number
Number (ABN)
(ABN)
Phone number (including area code)
Type of leave entitlement payment
$
Number of working days covered by the payment
Q14.DatePaid Payable.2.D
Q14.DatePaid Payable.2.M
Q14.DatePaid Payable.2.Y
You
Your partner
Employer’s details Name of business
Australian
Business Number
Number (ABN)
(ABN)
Phone number (including area code)
No
Yes
Fields on page 6
No
Yes
No
in a
Yes
No
Is the
Yes
No
transfer of assets to or their value
Yes
No
Yes
No
Is the private trust a Special Disability Trust (SDT)
No
Yes
No
Yes
Fields on page 7
No
you or have you (and/or
Yes
No
Securities
Yes
No
transfer of assets to or less than their value
Yes
No
If you do not have
Yes
No
Yes
No
been able to claim
Yes
No
Yes
No
Yes
Fields on page 8
No
Yes
DummyCalcQ31
Type of payment
Country which pays it
Who pays it
Date commenced (if
commenced (if known)
(if known)
You
Your partner
Type of payment
Country which pays it
Who pays it
Date commenced (if
commenced (if known)
(if known)
You
Your partner
No
Yes
Give details below
Name of person
Relationship to you
Number of meals you provide each day
$
Date started
started paying (DD
paying (DD MM YYYY)
Your share
% Partner’s share
Name of person
Relationship to you
Number of meals you provide each day
$
Date started
started paying (DD
paying (DD MM YYYY)
Your share
% Partner’s share
No
Yes
Fields on page 9
No
Yes
Give details below
Type of lump sum
Who paid it
$
Date paid (DD MM
paid (DD MM YYYY)
(DD MM YYYY)
You
Your partner
Type of lump sum
Who paid it
$
Date paid (DD MM
paid (DD MM YYYY)
(DD MM YYYY)
You
Your partner
Name of bank, building society or credit union
Account number (this may not be your card number)
Current balance of account
Currency if not AUD
Your share
share
Name of bank, building society or credit union
Account number (this may not be your card number)
Current balance of account
Currency if not AUD
Your share
share
Fields on page 10
Name of bank, building society or credit union
Account number (this may not be your card number)
Current balance of account
Currency if not AUD
Your share
share
Name of bank, building society or credit union
Account number (this may not be your card number)
Current balance of account
Currency if not AUD
Your share
share
Name of bank, building society or credit union
Account number (this may not be your card number)
Current balance of account
Currency if not AUD
Your share
%
Name of bank, building society or credit union
Account number (this may not be your card number)
Current balance of account
Currency if not AUD
Your share
share
$
$
Your share
share
No
Yes
Give details below
Type of asset (for example, car)
Make (for example, Ford)
Model (for example, Focus)
Year
$
$
Your share
share
Type of asset (for example, car)
Make (for example, Ford)
Model (for example, Focus)
Year
$
$
Your share
share
Fields on page 11
No
Yes
Give details below
Type of asset (for example, boat)
Make (for example, Quintrex)
Model (for example, Coastrunner)
Year
$
$
Your share
share
Type of asset (for example, caravan) (for
Make (for example, Jayco)
Model (for example, Heritage)
Year
$
$
Your share
%
No
life interest means you
Yes
No
Yes
Go to next question
No
Yes
No
Yes
No
real
Yes
How many other properties in and/or you (and/or your partner) own or have
Fields on page 12
No
Yes
Give details below
Name of institution/fund manager or SPIN code
Name of fund
Product reference number Current
$
(DD MM YYYY)
Current market value
market value
Owned by: You
Your partner
Name of institution/fund manager or SPIN code
Name of fund
Product reference number Current
$
(DD MM YYYY)
Current market value
market value
Owned by: You
Your partner
No
Yes
Give details in the next column
Fields on page 13
Name of product provider/SMSF/SAF
Type of income stream
Product reference number
(DD MM YYYY)
(DD MM YYYY)
Q46.DateJoin.1.Y
Owned by: You
Your partner
Name of product provider/SMSF/SAF
Type of income stream
Product reference number
(DD MM YYYY)
(DD MM YYYY)
Q46.DateJoin.2.Y
Owned by: You
Your partner
No
Yes
Give details below
Name of the public company or ASX code
Number of shares held
Country if not Australia
Your share
share
Name of the public company or ASX code
Number of shares held
Country if not Australia
Your share
share
Name of the public company or ASX code
Number of shares held
Country if not Australia
Your share
share
Name of the public company or ASX code
Number of shares held
Country if not Australia
Your share
share
Fields on page 14
No
Yes
Give details below
Name of public company
Type of shares
Number of shares
$
Your share share
%
Name of public company
Type of shares
Number of shares
$
Your share share
%
Name of public company
Type of shares
Number of shares
$
Your share share
%
No
Yes
Give details below
Name of company
Name of product and product option
Number of units held (if applicable)
APIR code (if known)
Value of the investment
Currency if not AUD
Your share
if not AUD
Name of company
Name of product and product option
Number of units held (if applicable)
APIR code (if known)
Value of the investment
Currency if not AUD
Your share
share
Fields on page 15
No
Yes
Give details below
Name of margin loan company
$
APIR code (if known)
Your share
share
Name of margin loan company
$
APIR code (if known)
Your share
share
No
Yes
Give details below
Name of company
Type of investment
Current amount invested Currency
Currency if not AUD
Your share
share
Name of company
Type of investment
Current amount invested Currency
Currency if not AUD
Your share
share
Name of company
Type of investment
Current amount invested Currency
Currency if not AUD
Your share
share
Fields on page 16
No
Yes
Give details below
Who did you lend the money to
Date lent (DD MM YYYY)
Date lent (DD MM YYYY)
Date lent (DD MM YYYY)
$
$
you
% your partner
Who did you lend the money to
Date lent (DD MM YYYY)
Date lent (DD MM YYYY)
Date lent (DD MM YYYY)
$
$
you
% your partner
No
Yes
Give details below
Name of the organisation agreement entered into with
No
Yes
Give details below
What you gave away or sold for less than its market value (for example, money, car, second home, land, farm)
(DD MM YYYY)
second home, land,
home, land, farm)
$
$
Your share share
%
% No
Yes
What you gave away or sold for less than its market value (for example, money, car, second home, land, farm)
(DD MM YYYY)
(DD MM YYYY)
Q54.DateGiven.2.Y
$
$
Your share share
%
% No
Yes
What you gave away or sold for less than its market value (for example, money, car, second home, land, farm)
(DD MM YYYY)
(DD MM YYYY)
Q54.DateGiven.3.Y
$
$
Your share share
%
% No
Yes
Fields on page 17
No
funeral
Yes
Name of company
Name of product
$
$
Your share
share
Name of company
Name of product
$
$
Your share
share
No
Yes
No
Yes
Give details below
Name of insurance company
Policy number
$
Your share
value
Name of insurance company
Policy number
$
Your share
value
Fields on page 18
No
Yes
Give details below
Type of payment
Who pays it
$
Date commenced (if
commenced (if known)
(if known)
Your share
MM YYYY)
Type of payment
Who pays it
$
Date commenced (if
commenced (if known)
(if known)
Your share
share
No
Yes
Give details below
Description of asset
Current market value
Balance of loan(s) taken to purchase
Currency if not AUD
Your share share
%
Description of asset
Current market value
Balance of loan(s) taken to purchase
Currency if not AUD
Your share share
%
Fields on page 19
Copies of the 2 most recent payslips from each
Copies of documents with details of the fringe
Seasonal, Contract and Intermittent Work
Employment Separation Certificate (SU001) form,
Employment Separation Certificate (SU001) form
Business details (Mod F) form and Real estate
Copy of evidence of the vesting
Private Trust (Mod PT) form
Special Disability Trust (Mod SDT) form
Copies of the most recent Income Tax Return and
Copy of evidence of deregistration
Private Company (Mod PC) form
Copies of the most recent Income Tax Return and
Compensation and damages (Mod C) form
Copy of income protection policy document and the
Copies of documents with details of payments
Real estate details (Mod R) form
Copies of the latest statements for superannuation
A Centrelink/DVA schedule or similar schedule or a
Copies of the latest statement for each
Copies of the latest statement for each
Copies of managed investment certificates or
Copies of the latest statement for margin loans
Copies of investment documents for each bond or
Copies of money on loan documents (if available)
Copy of the loan agreement or contract
Copy of document with details of each bond or
Copies of funeral service contract
Copies of insurance policy documents and latest
Copy of the most recent statement or certificate
Fields on page 20
61
Your signature
Date (DD MM
(DD MM YYYY)
MM YYYY)
Partner’s signature
Date (DD MM
(DD MM YYYY)
MM YYYY)
