Claim for a Commonwealth Seniors Health Card

Claim for a Commonwealth Seniors Health Card When to use this form Who can claim a Commonwealth Seniors Health Card Use this form to claim a Commonwealth Seniors Health Card for yourself and your partner. The Commonwealth Seniors Health Card provides you with access to Pharmaceutical Benefits Scheme (PBS) prescription medicines and certain Medicare services at the concessional rate. The card also entitles you to a quarterly supplement payment if you qualify. State, territory and local governments, and some private providers, may offer additional concessions at their own discretion. You must be age pension age to make a claim for a Commonwealth Seniors Health Card. te: Do not lodge this claim until you have reached age pension age (refer to the Information Booklet for the qualifying age for Commonwealth Seniors Health Card). You cannot receive a Commonwealth Seniors Health Card if you are already receiving any of the following: Centrelink pension or benefit Department of Veterans Affairs Service Pension Department of Veterans Affairs Age Pension Department of Veterans Affairs Income Support Supplement Department of Veterans Affairs Commonwealth Seniors Health Card. If you have been receiving any of the above assistance and it will be cancelled soon, do not lodge your claim for the Commonwealth Seniors Health Card until after the cancellation date. If your partner is receiving an entitlement from the Department of Veterans Affairs, you may still be entitled to a Commonwealth Seniors Health Card from the Australian Government Department of Human Services and both of you should complete this claim form. Contact the Department of Veterans Affairs for information on what you are receiving and what further entitlements you may have from them. The Commonwealth Seniors Health Card does not cover dependants and/or partners, only the cardholder. If you have dependants, or a partner who is not eligible for a Commonwealth Seniors Health Card, it is important you read the section on Low Income Health Care Card in the Information Booklet. What else you will need to provide Online Services You may need to provide identity documents. There is a list of acceptable documents in the Confirming your identity form (SS231). If you do not have this form, go to www. humanservices.gov.au/forms You can access your Centrelink online account through mygov. mygov is a simple and secure way to access a range of government services online with one username and password. You can create a mygov account at www.my.gov.au and link it to your Centrelink online account. To make a claim online, access your Centrelink online account through mygov, then select Online Claims from the menu. 1 of 19

Filling in this form Returning your form For more information Please use black or blue pen. Print in BLOCK LETTERS. Mark boxes like this with a or. Where you see a box like this Go to 5 skip to the question number shown. You do not need to answer the questions in between. Check that all required questions are answered and that the form is signed and dated. Return this form and any supporting documents to us within 14 days so we can process your application or claim. If you cannot do this within 14 days, contact us for extra time. If extra time is required, you must contact us at the earliest possible date to make an arrangement. You cannot lodge your claim form before reaching age pension age or while you are entitled to any of the assistance listed on page 1. You can return this form and any supporting documents: online submit your documents online (excluding identity documents). For more information about how to access an Online Account or how to lodge documents online, go to www.humanservices.gov.au/submitdocumentsonline by post. in person if you are unable to submit this form and any supporting documents online or by post, you can provide them in person to one of our service centres. Refer to the Information you need to know about your claim for Commonwealth Seniors Health Card, Low Income Health Care Card and Ex-Carer Allowance (Child) Health Care Card (Ci010) (Information Booklet) at www.humanservices.gov.au/seniorshealthcard or call us on 132 300 or visit one of our service centres. If you need a translation of any documents for our business, we can arrange this for you free of charge. To speak to us in languages other than English, call 131 202. te: Call charges apply calls from mobile phones may be charged at a higher rate. If you have a hearing or speech impairment, you can contact the TTY service Freecall 1800 810 586. A TTY phone is required to use this service. 2 of 19

Please read this before completing this claim form. Under social security law, claims for the Commonwealth Seniors Health Card cannot be lodged before a person has reached age pension age. Please lodge this form either on, or after, the date you reach age pension age. Please see the Information Booklet for more details on the qualifying age for the Commonwealth Seniors Health Card. 1 2 Do you need an interpreter when dealing with us? This includes an interpreter for people who have a hearing or speech impairment. Go to 4 What is your preferred spoken language? 3 What is your preferred written language? 4 Do you have a partner? Go to 7 5 Is your partner also claiming the Commonwealth Seniors Health Card? You will still need to give your partner s personal and income details. You will not be required to provide identity documents for your partner. If you are both eligible you will both get a Commonwealth Seniors Health Card. CLK0SA296 1607 3 of 19

6 Please read this before answering the following questions. Please complete the left hand column for yourself. (if you have one) should complete ALL questions in the right hand column, unless instructed otherwise, even if they are not claiming a Commonwealth Seniors Health Card. This will enable your entitlement to be assessed. You 7 Do you receive a Centrelink pension or benefit? You cannot get a Commonwealth Seniors Health Card. 7 Do you receive a Centrelink pension or benefit? Your Centrelink Reference Number (if known) You need to complete this form if you have a partner and your partner is also claiming a Commonwealth Seniors Health Card. If your pension or benefit will be cancelled soon, do not lodge this claim until after the cancellation date. Go to 10 You cannot get a Commonwealth Seniors Health Card. You only need to complete this form if your partner is also claiming a Commonwealth Seniors Health Card. If your pension or benefit will be cancelled soon, do not lodge this claim until after the cancellation date. Go to 10 8 Do you receive a service pension or income support supplement from the Department of Veterans Affairs? You cannot get a Commonwealth Seniors Health Card. 8 Do you receive a service pension or income support supplement from the Department of Veterans Affairs? Your Department of Veterans Affairs Service Number You need to complete this form if you have a partner and your partner is also claiming a Commonwealth Seniors Health Card. If your Service Pension or income support supplement will be cancelled soon, do not lodge this claim until after the cancellation date. Go to 10 You cannot get a Commonwealth Seniors Health Card. You only need to complete this form if your partner is also claiming a Commonwealth Seniors Health Card. If your Service Pension or income support supplement will be cancelled soon, do not lodge this claim until after the cancellation date. Go to 10 9 Do you have a Department of Veterans Affairs Commonwealth Seniors Health Card? You cannot get a Commonwealth Seniors Health Card. 9 Do you have a Department of Veterans Affairs Commonwealth Seniors Health Card? Your Centrelink Reference Number (if known) You need to complete this form if you have a partner and your partner is also claiming a Commonwealth Seniors Health Card. If your Department of Veterans Affairs Commonwealth Seniors Health Card will be cancelled soon, do not lodge this claim until after the cancellation date. Your Department of Veterans Affairs Service Number You cannot get a Commonwealth Seniors Health Card. You only need to complete this form if your partner is also claiming a Commonwealth Seniors Health Card. If your Department of Veterans Affairs Commonwealth Seniors Health Card will be cancelled soon, do not lodge this claim until after the cancellation date. 4 of 19

10 Your name Mr Mrs Family name Miss Ms Other 10 Your name Mr Mrs Family name Miss Ms Other First given name First given name Second given name Second given name 11 Have you ever used or been known by any other name (e.g. name at birth, maiden name, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name)? 1 Give details below Other name 11 Have you ever used or been known by any other name (e.g. name at birth, maiden name, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name)? 1 Give details below Other name Type of name (e.g. name at birth) Type of name (e.g. name at birth) 2 Other name 2 Other name Type of name (e.g. maiden name) Type of name (e.g. maiden name) If you have more than 2 other names, attach a separate sheet with details. If you have more than 2 other names, attach a separate sheet with details. 12 Your sex Male Female 12 Your sex Male Female 13 Your date of birth 13 Your date of birth Attach an original document as proof of your date of birth. If you are claiming Commonwealth Seniors Health Card, attach an original document as proof of your date of birth. 5 of 19

14 Your permanent address 14 Your permanent address Postcode Postcode 15 Your postal address (if different to above) 15 Your postal address (if different to above) Postcode Postcode 16 Please read this before answering the following question. 16 Please read this before answering the following question. If you provide an email address or mobile phone number, you may receive electronic messages (SMS or email) from us. To read the Terms and Conditions, go to www. humanservices.gov.au/em or visit one of our service centres. If you provide an email address or mobile phone number, you may receive electronic messages (SMS or email) from us. To read the Terms and Conditions, go to www. humanservices.gov.au/em or visit one of our service centres. Your contact details Your contact details Home phone number ( ) Home phone number ( ) Is this a silent number? Is this a silent number? Mobile phone number Mobile phone number Fax number ( ) Fax number ( ) Work phone number ( ) Work phone number ( ) Alternative phone number ( ) Alternative phone number ( ) Email Email @ @ 17 Questions 17 and 18 are optional and will not affect your Commonwealth Seniors Health Card. If you do answer, the information will help us to continue to improve services to Aboriginal, Torres Strait Islander Australians and Australian South Sea Islanders. Australian South Sea Islanders are the descendants of Pacific Islander labourers brought from the Western Pacific in the 19th Century. 17 Questions 17 and 18 are optional and will not affect your Commonwealth Seniors Health Card. If you do answer, the information will help us to continue to improve services to Aboriginal, Torres Strait Islander Australians and Australian South Sea Islanders. Australian South Sea Islanders are the descendants of Pacific Islander labourers brought from the Western Pacific in the 19th Century. Are you of Aboriginal or Torres Strait Islander Australian origin? If you are of both Aboriginal and Torres Strait Islander Australian origin, please tick both boxes. Are you of Aboriginal or Torres Strait Islander Australian origin? If you are of both Aboriginal and Torres Strait Islander Australian origin, please tick both boxes. Aboriginal Australian Torres Strait Islander Australian Aboriginal Australian Torres Strait Islander Australian 18 Are you of Australian South Sea Islander origin? 6 of 19 18 Are you of Australian South Sea Islander origin?

19 Please read this before answering the following question. We recognise both opposite-sex and same-sex relationships. This includes de facto relationships and relationships registered under state or territory law. Select ONE option below that best describes your current relationship status. What is your CURRENT relationship status? Married Go to 20 Registered relationship (opposite-sex or same-sex relationship registered under state or territory law) Go to 20 Partnered (living together in an opposite-sex or same-sex relationship, including de facto) Go to 21 Separated (previously lived with an opposite-sex or same-sex partner, including in a marriage, registered or de facto relationship) Go to 26 Divorced Go to 26 Widowed (previously partnered with an opposite-sex or same-sex partner, including in a marriage, registered or de facto relationship) Go to 26 Never married or lived with a partner Go to 27 20 What is your date of marriage or relationship registration? Go to 22 21 When did you and your partner start living together as a member of a couple? 22 Do you currently live in the same home as your partner? Go to 25 23 Why are you not living with your partner? Partner s illness Your illness Partner in prison Partner s employment Other Give details below 7 of 19

24 Period not living with your partner To OR indefinite Go to 27 25 Do you give permission for your partner to discuss your entitlements with us? You can change this authority at any time. 25 Do you give permission for your partner to discuss your entitlements with us? You can change this authority at any time. Go to 27 Go to 27 26 Date divorced, widowed or separated 27 Do you want to authorise another person or organisation to make enquires, get payments and/or act on your behalf? 27 Do you want to authorise another person or organisation to make enquiries, get payments and/or act on your behalf? You will need to complete and attach an Authorising a person or organisation to enquire or act on your behal form (SS313). If you do not have this form or want more information about nominee arrangements, go to www. humanservices.gov.au/nominees You will need to complete and attach an Authorising a person or organisation to enquire or act on your behal form (SS313). If you do not have this form or want more information about nominee arrangements, go to www. humanservices.gov.au/nominees 28 Please read this before answering the questions about tax. 28 Please read this before answering the questions about tax. You are not breaking the law if you do not give us your tax file number, but if you do not provide it to us, or authorise us to get it from the Australian Taxation Office, you (and your partner if you have one) may not be granted a Commonwealth Seniors Health Card. In giving us your tax file number in relation to this claim you authorise us to use your tax file number for other social security payments and services in future where necessary. You are not breaking the law if you do not give us your tax file number, but if you do not provide it to us, or authorise us to get it from the Australian Taxation Office, you (and your partner if you have one) may not be granted a Commonwealth Seniors Health Card. In giving us your tax file number in relation to this claim you authorise us to use your tax file number for other social security payments and services in future where necessary. Have you given us your tax file number before? Have you given us your tax file number before? t sure Go to 30 t sure Go to 30 29 Do you have a tax file number? 29 Do you have a tax file number? Please call us on 132 300 Your tax file number Please call us on 132 300 Your tax file number 8 of 19

30 Please read this before answering the following question. 30 Please read this before answering the following question. Permanently means you normally live in Australia on a long-term basis. Holidays or short trips outside Australia would not affect this. Permanently means you normally live in Australia on a long-term basis. Holidays or short trips outside Australia would not affect this. Are you living in Australia permanently? Are you living in Australia permanently? 31 Have you EVER lived or travelled outside Australia, including short trips and holidays? 31 Have you EVER lived or travelled outside Australia, including short trips and holidays? This question assists us to verify your Australian residence. This question assists us to verify your Australian residence. Give details below Give details below Year you last entered Australia Year you last entered Australia Passport number Passport number Country of issue Country of issue 32 Are you an Australian citizen who was born in Australia? 32 Are you an Australian citizen who was born in Australia? You will need to provide proof of your Australian residence status (e.g. citizenship papers, passport or other documentation). You will need to provide proof of your Australian residence status (e.g. citizenship papers, passport or other documentation). Go to 42 Go to 42 33 What is your country of birth? 33 What is your country of birth? 34 When did you start living in Australia? 34 When did you start living in Australia? 35 Did you start living in Australia before 1965? 35 Did you start living in Australia before 1965? Give details below Give details below Name of the ship or airline on which you arrived Name of the ship or airline on which you arrived Name of the place where you first arrived/disembarked Name of the place where you first arrived/disembarked What was your name when you first arrived in Australia? What was your name when you first arrived in Australia? 9 of 19

36 What is your country of citizenship? Australia Date granted 36 What is your country of citizenship? Australia Date granted Other Country of citizenship Go to 42 Other Country of citizenship Go to 42 37 What type of visa did you arrive on? New Zealand passport (special category visa) Permanent Temporary Unknown (e.g. arrived on parent s passport) Go to 39 Go to 39 37 What type of visa did you arrive on? New Zealand passport (special category visa) Permanent Temporary Unknown (e.g. arrived on parent s passport) Go to 39 Go to 39 38 Your visa details on arrival Visa sub class Date visa granted 38 Your visa details on arrival Visa sub class Date visa granted 39 Has your visa changed since you arrived in Australia? Most recent visa details Visa sub class Date visa granted 39 Has your visa changed since you arrived in Australia? Most recent visa details Visa sub class Date visa granted 40 Are you a refugee or former refugee? 40 Are you a refugee or former refugee? 41 Did either of your parents arrive on a refugee or humanitarian visa? 41 Did either of your parents arrive on a refugee or humanitarian visa? 10 of 19

42 Please read this before answering the following question. 42 Please read this before answering the following question. We need to know if you have lived in countries other than Australia from birth through to the present. Lived means where you/your family made your home or spent a long period of time it does not include places you visited. We need to know if you have lived in countries other than Australia from birth through to the present. Lived means where you/your family made your home or spent a long period of time it does not include places you visited. Except for short trips or holidays, have you EVER lived outside Australia? Except for short trips or holidays, have you EVER lived outside Australia? List ALL countries, INCLUDING AUSTRALIA, you have lived in SINCE BIRTH. If you were born outside Australia, include the country where you were born. Include the periods you have lived in each country. Do NOT include short trips or holidays. List ALL countries, INCLUDING AUSTRALIA, you have lived in SINCE BIRTH. If you were born outside Australia, include the country where you were born. Include the periods you have lived in each country. Do NOT include short trips or holidays. 1 1 To To 2 2 To To 3 3 To To 4 4 To To 5 5 To To If you require more space, attach a separate sheet with details. If you require more space, attach a separate sheet with details. 11 of 19

43 Please read this before answering the following questions. The applicable Commonwealth Seniors Health Card income limit is increased by $639.60 for each dependent child you have. For the purposes of the Commonwealth Seniors Health Card income test dependent child means: For a young person under 16 years of age a young person for whom you have legal responsibility, either alone or jointly, for their day-to-day care, welfare and development. Or, if you are not legally responsible, the young person is not a dependent child of someone else and is wholly or substantially in your care, and if the young person is not in full-time education, they must not be in receipt of income above a certain limit, called the dependency limit, and the young person is not receiving a social security pension or benefit, and if the young person is not an Australian resident, they are living with you. For a young person between 16 and 21 years of age the young person is wholly or substantially dependent on you, and the young person s financial year income does not exceed the personal income limit, and the young person is not receiving a social security pension or benefit, and if the young person is not an Australian resident, they are living with you. Please refer to the Information Booklet for more information about dependent children. Go towww.humanservices.gov.au/seniorshealthcard for the current dependency limits and personal income limits. Do you (and/or your partner) have any dependent children? Give the following details of each child If you have more than 2 dependent children, attach a separate sheet with details. Child 1 44 Family name Child 2 44 Family name First given name First given name Second given name Second given name 45 Has this child ever been known by any other names? List the other names 45 Has this child ever been known by any other names? List the other names 46 Sex Male Female 46 Sex Male Female 47 Date of birth 47 Date of birth 48 Do you receive Family Tax Benefit for this child? 48 Do you receive Family Tax Benefit for this child? Attach proof of birth (e.g. birth certificate) for this child if you have not previously provided it to us. Attach proof of birth (e.g. birth certificate) for this child if you have not previously provided it to us. 12 of 19

49 If you wish to receive any quarterly supplement payments you may be entitled to, you must provide details of a bank account into which the payments can be made. You may choose not to receive the supplement payments and this will not affect your eligibility for a Commonwealth Seniors Health Card. If at any time in the future you change your mind and wish to receive these payments, they will commence from when you provide your bank account details. For more information, go to www. humanservices.gov.au/seniorshealthcard 49 If you wish to receive any quarterly supplement payments you may be entitled to, you must provide details of a bank account into which the payments can be made. You may choose not to receive the supplement payments and this will not affect your eligibility for a Commonwealth Seniors Health Card. If at any time in the future you change your mind and wish to receive these payments, they will commence from when you provide your bank account details. For more information, go to www. humanservices.gov.au/seniorshealthcard Do you wish to receive any relevant quarterly supplement payments? Do you wish to receive any relevant quarterly supplement payments? Go to 51 Go to 51 50 You must give your bank account details to get the payments. Where do you want your payment made? The bank, building society or credit union account must be in your name. A joint account is acceptable. Name of bank, building society or credit union Branch where the account is held Branch number (BSB) Account number (this may not be your card number) Account held in the name(s) of 50 You must give your bank account details to get the payments. Where do you want your payment made? The bank, building society or credit union account must be in your name. A joint account is acceptable. Name of bank, building society or credit union Branch where the account is held Branch number (BSB) Account number (this may not be your card number) Account held in the name(s) of 13 of 19

51 News for Seniors News for Seniors is a free publication produced by us that keeps you informed of issues concerning government benefits, services and other associated support arrangements. Would you like to receive News for Seniors? Go to 54 51 News for Seniors News for Seniors is a free publication produced by us that keeps you informed of issues concerning government benefits, services and other associated support arrangements. Would you like to receive News for Seniors? Go to 54 52 How would you like to receive News for Seniors? Online Mail Go to 54 52 How would you like to receive News for Seniors? Online Mail Go to 54 53 How would you like to be notified that the latest edition of News for Seniors is available? Email SMS Online letters 53 How would you like to be notified that the latest edition of News for Seniors is available? Email SMS Online letters 54 The Low Income Health Care Card offers concessions for your dependents as well as yourself. You may be eligible for a Low Income Health Care Card if your income is below the applicable limit. For more information, go to www.humanservices.gov.au/lic Do you wish to apply for a Low Income Health Care Card? You will need to complete and attach a Claim for a Health Care Card form (SS050). If you do not have this form, go to www.humanservices.gov.au/lic 55 Please read this before answering the following questions. The income details you provide can be for either of the 2 financial years preceding the current financial year. They should be the most recent verifiable details. You and your partner MUST provide income details for the same financial year. Go to next page 14 of 19

56 For which financial year are you (and your partner) providing income details? / 57 A B Give the following income details for the financial year you have indicated in question 56. Taxable income Attach an original tice of Assessment issued by the Australian Taxation Office.* OR If your (and/or your partner s) income was too low and you are not required to lodge a tax return, give the amount of income you (and/or your partner) received. Only include income that is taxable and is not income from sources requested in Parts B to E of this question. Attach documents to verify this amount.* Foreign income you did not pay Australian income tax on (write the amount in Australian dollars). Attach your tax return or if you (and/or your partner) are not required to lodge a tax return, other documents to verify this amount.* You $ $ AUD $ OR OR $ + + AUD C D F Total net investment loss Total net investment loss is the sum of: Net rental property losses (see the Income tests section of your tax return) the amount by which the expenses incurred for a rental property exceed the gross rental income from that property. AND Net financial investment losses (see the Income tests section of your tax return) the amount by which allowable deductions in respect of financial investments exceed the gross income from those investments. For Commonwealth Seniors Health Card purposes most deductions allowed by the Australian Taxation Office are allowed as a deduction. te: You must ADD this amount even though it is a loss because such a loss will have reduced your taxable income. Attach your tax return or if you (and/or your partner) are not required to lodge a tax return, other documents to verify this amount.* Value of employer provided benefits above $1,000. Write the total amount of your employer provided benefits less the first $1,000. Attach payment summary.* Total income (A + B + C + D + E = F) $ $ $ + + + + E + + Reportable superannuation contributions are the sum of your: reportable employer superannuation contributions (see the Income tests section of your tax return), for example, salary sacrifice contributions. Attach payment summary.* and personal deductible superannuation contributions (see the Supplementary section of your tax return). Contributions for which an individual can claim a deduction on their individual tax return. Attach tax return or if you (and/or your partner) are not required to lodge a tax return, other documents to verify this amount.* $ $ = $ $ $ = G Your (and your partner s) COMBINED TOTAL ADJUSTED TAXABLE INCOME. $ * Attach the required documents, if you have provided an amount for A, B, C, D and/or E. 15 of 19

58 Please read this before answering the following question. An account-based pension (also known as an allocated pension or transition to retirement pension) is a retirement income stream product purchased with superannuation money. Unlike other annuities and superannuation pensions, most investors have full access to their capital. Although there is a minimum amount that must be paid each year, the investor may nominate to receive an amount above the minimum. Account-based pensions are tax free from 60 years of age. If you (or your partner) own any account-based pensions, income may be deemed on the account balance of the pension and added to any other income amounts you have declared to determine whether you are entitled to a Commonwealth Seniors Health Card. Do you (or your partner) receive income from an account-based pension? Go to 60 Give details below 59 Is the COMBINED TOTAL ADJUSTED TAXABLE INCOME listed at 57G plus any deemed income from your (and your partner s) account-based pension, below or above the income limit for the Commonwealth Seniors Health Card? Go to www.humanservices.gov.au/deeming for the current deeming rates and www. humanservices.gov.au/seniorshealthcard for the current income limits. Below the income limit Above the income limit Do not complete 60 to 62. Go to 63 You may still be eligible if your income will be below the income limits in the current financial year. Go to 61 1 You (and/or your partner) will need to attach a Details of income stream product form (SA330) or a similar schedule, for each account-based pension. The form or similar schedule must be completed by your product provider or the trustee of the Self Managed Superannuation Fund (SMSF) or Small APRA Fund (SAF) or the SMSF administrator. If you do not have this form, go to www. humanservices.gov.au/forms Name of product provider/smsf/saf 60 The COMBINED TOTAL ADJUSTED TAXABLE INCOME listed at 57G is the income we will use to work out your eligibility. Is the COMBINED TOTAL ADUSTED TAXABLE INCOME at question 57G, below or above the income limit for the Commonwealth Seniors Health Card? Go to www.humanservices.gov.au/seniorshealthcard for the current income limits. Below the income limit Above the income limit Do not complete 61 and 62. Go to 63 You may still be eligible if your income will be below the income limits in the current financial year. Product reference number Commencement date Owned by: You 61 Will your (and your partner s) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 56? 2 Name of product provider/smsf/saf Product reference number Commencement date The same Higher You are not eligible for a Commonwealth Seniors Health Card because your income is too high. Do NOT continue with this claim. Owned by: You If you (and/or your partner) have more than 2 accountbased pensions, attach a separate sheet with details. Lower Give details below Why will your income be lower (e.g. stopped working, previously sold significant asset(s) to pay for medical expenses, ceased operating a business)? You will need to attach evidence to support the reason your (and your partner s) income will be lower. 16 of 19

62 A B C D F Give an estimate of the income you (and your partner) expect to receive in the current financial year. Estimated taxable income OR If your (and/or your partner s) income will be too low and you are not required to lodge a tax return, give the amount of income you (and/or your partner) expect to receive. Only include income that is taxable and is not income from sources requested in Parts B to E of this question. Foreign income you do not pay Australian income tax on (write the amount in Australian dollars). Total net investment loss Total net investment loss is the sum of: Net rental property losses the amount by which the expenses incurred for a rental property exceed the gross rental income from that property. AND Net financial investment losses the amount by which allowable deductions in respect of financial investments exceed the gross income from those investments. For Commonwealth Seniors Health Card purposes most deductions allowed by the Australian Taxation Office are allowed as a deduction. te: You must ADD this amount even though it is a loss because such a loss will have reduced your taxable income. Value of employer provided benefits above $1,000. Write the total amount of your employer provided benefits less the first $1,000. Total income (A + B + C + D + E = F) $ $ $ $ + + + + $ $ + + $ $ E + + Reportable superannuation contributions are the sum of your: reportable employer superannuation contributions, for example, salary sacrifice contributions, and personal deductible superannuation contributions. Contributions for which an individual can claim a deduction on their individual tax return. AUD OR $ $ = $ $ AUD OR = G Your (and your partner s) COMBINED ESTIMATED ADJUSTED TAXABLE INCOME. This total adjusted taxable income plus any deemed income you (and your partner) may have from any account-based pensions will be used to work out your eligibility. $ 17 of 19

63 Which of the following forms, documents and other attachments are you providing with this form? If you are not sure, check the question to see if you should attach the documents. Where you are asked to supply identity documents, please attach original documents. Confirmation of identity There is a list of acceptable documents in the Confirming your identity form (SS231) Proof of your date of birth (see question 13) Authorising a person or organisation to enquire or act on your behal form (SS313) (If you answered at question 27) Proof of Australian residence status (If you answered at question 32) Dependent children proof of birth (see question 48) Claim for a Health Care Card form (SS050) (If you answered at question 54) Original tice of Assessment or if you are not required to lodge a tax return, other documents to verify this amount (see question 57A) Tax return or if you are not required to lodge a tax return, other documents to verify this amount (see question 57B) Tax return or if you are not required to lodge a tax return, other documents to verify this amount (see question 57C) Payment summary (see question 57D) Payment summary and/or tax return or if you are not required to lodge a tax return, other documents to verify this amount (see question 57E) A Details of income stream product form (SA330) or a similar schedule (If you answered at question 58) Documents to support the reason your income will be lower (see question 61) 63 Which of the following forms, documents and other attachments are you providing with this form? If you are not sure, check the question to see if you should attach the documents. Where you are asked to supply identity documents, please attach original documents. If you are claiming, confirmation of identity There is a list of acceptable documents in the Confirming your identity form (SS231) If you are claiming, proof of your date of birth (see question 13) Authorising a person or organisation to enquire or act on your behal form (SS313) (If you answered at question 27) Proof of Australian residence status (If you answered at question 32) Original tice of Assessment or if you are not required to lodge a tax return, other documents to verify this amount (see question 57A) Tax return or if you are not required to lodge a tax return, other documents to verify this amount (see question 57B) Tax return or if you are not required to lodge a tax return, other documents to verify this amount (see question 57C) Payment summary (see question 57D) Payment summary and/or tax return or if you are not required to lodge a tax return, other documents to verify this amount (see question 57E) A Details of income stream product form (SA330) or a similar schedule (If you answered at question 58) Documents to support the reason your income will be lower (see question 61) 18 of 19

64 IMPORTANT INFORMATION Privacy and your personal information Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law. You can get more information about the way in which the Department of Human Services will manage your personal information, including our privacy policy, at www. humanservices.gov.au/privacy or by requesting a copy from the department. 64 IMPORTANT INFORMATION Privacy and your personal information Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law. You can get more information about the way in which the Department of Human Services will manage your personal information, including our privacy policy, at www. humanservices.gov.au/privacy or by requesting a copy from the department. 65 Statement I declare that: the information I have provided on this form is complete and correct. I understand that: giving false or misleading information is a serious offence. I may need to give further information if requested. the Australian Government Department of Human Services can make relevant enquiries to make sure I receive the correct entitlement. I must notify the Australian Government Department of Human Services of any changes to this information within 14 days of the change occurring. 65 Statement I declare that: the information I have provided on this form is complete and correct. I understand that: giving false or misleading information is a serious offence. I may need to give further information if requested. the Australian Government Department of Human Services can make relevant enquiries to make sure I receive the correct entitlement. I must notify the Australian Government Department of Human Services of any changes to this information within 14 days of the change occurring. Your signature Your signature Date Date 19 of 19