Fillable Printable Income and Assets Sample Form
Fillable Printable Income and Assets Sample Form
Income and Assets Sample Form
SA369.1409
Income and Assets
1 of 17
This form asks you to provide information about your income and assets.
This information is used to calculate your Centrelink payment.
Purpose of this form
Filling in this form
• 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.
Returning your form
Check that you have answered all the questions you need to answer, and that you
(and your partner) have signed and dated this form.
You can return this form and any supporting documents:
• online – submit your documents online. 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.
For more information
Go to our websitewww.humanservices.gov.au/dsp orwww.humanservices.gov.au/carerpayment
or
www.humanservices.gov.au/agepension or call us on 132 717 for Disability, Sickness and
Carers or 132 300 for Seniors 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.
Note: 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 on
Freecall™ 1800 810 586. A TTY phone is required to use this service.
Online Services
You can access your Centrelink, Medicare and Child Support Online Services through myGov.
myGov is a fast, simple way to access a range of government services online with one
username, one password, all from one secure location. To create a myGov account, go to www.
my.gov.au
You must tell us about your partner’s income and assets.
You can complete this form for both you and your partner.
OR
You may choose to complete an
Income and Assets
form (SA369) separately.
If you choose this option, tick this box
If you need more copies of this form, go to our website
www.humanservices.gov.au/forms
If you have a partner
SA369.1409
2 of 17
Your date of birth
/ /
2
Your name
Other
Family name
1
First given name
Second given name
MsMissMrsMr
Your Centrelink Reference Number (if known)
3
Do you have a partner?
4
Go to next question
Go to 8
No
Yes
Your partner’s date of birth
/ /
6
Your partner’s name
Other
Family name
5
First given name
Second given name
MsMissMrsMr
Your partner’s Centrelink Reference Number (if known)
7
Do you (and/or your partner) CURRENTLY receive any
income from work other than self-employment?
8
Give details in the next column
Go to 10
No
Yes
If you (and/or your partner) currently get income from
more than 2 jobs, attach a separate sheet with details.
Attach the 2 most recent payslips from
each employer.
GROSS income from employment includes amounts
voluntarily salary sacrificed into superannuation and the
value of employer provided fringe benefits.
Address
Postcode
Phone number
( )
Employer’s name
1
Is this your usual wage?
Personnel, service or
clock-card number
Hours worked per fortnight
GROSS amount earned per
fortnight (before tax and
other deductions)
per fortnight$
Who works for this employer: You Your partner
Australian Business Number (ABN)
Is this work:
CasualSeasonalPart-timeFull-time
per fortnight
No Yes
Continued
Address
Postcode
Phone number
( )
Employer’s name
2
Is this your usual wage?
Personnel, service or
clock-card number
Hours worked per fortnight
GROSS amount earned per
fortnight (before tax and
other deductions)
per fortnight$
Who works for this employer: You Your partner
Australian Business Number (ABN)
Is this work:
CasualSeasonalPart-timeFull-time
per fortnight
No Yes
CLK0SA369 1409
SA369.1409
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Do you (and/or your partner) get any fringe benefits
provided by an employer (e.g. use of a car as part of a
salary package, rent/mortgage paid)?
9
Go to next question
No
Yes
Attach details that indicate the type of
fringe benefit and its value, and whether
or not the amount provided is ‘grossed up’
or not ‘grossed up’.
Fringe benefits – means a benefit received as part of
earned income but not as a wage or salary.
Are you (and/or your partner) claiming Age Pension?
10
Go to next question
No
Yes
Go to 12
Please read this before answering the following question.
11
Seasonal work is work that is available for part or parts
of the year at approximately the same time each year.
Contract work is any intermittent work that is performed
under a contract for a specific function and/or period
including sub-contract work.
Intermittent work is work that is available from time to
time, can reasonably be predicted to end or not be
available for a period, is less than a year in duration and
does not accrue leave entitlements.
In the last 6 months, have you (and/or your partner) done
any seasonal, contract or intermittent work?
Go to next question
No
Yes
You will need to complete and attach a
Seasonal, Contract and Intermittent
Work Details
form (SU496). If you do not
have this form,
go to our website
www.humanservices.gov.au/forms or call us.
Please read this before answering the following question.
12
The
current market value
of an item is what you
would get if you sold it. It is not the replacement or
insured value.
Include:
• all furniture (including soft furnishings such as
curtains), antiques and works of art
• electrical appliances such as televisions and fridges
• jewellery for personal use and hobby collections
(e.g. stamps, coins).
Do NOT include:
• fixtures such as stoves and built-in items.
What is your estimate of the current market value of your
(and/or your partner’s) household contents and personal
effects?
Current market value
Your share
Partner’s
share
$
Amount owed
$
%%
Do you (and/or your partner) have a life insurance policy
that can be cashed in?
13
Include:
• policies with a surrender value (e.g. whole of life, paid
up and endowment policies).
Do NOT include:
• friendly society bonds or life insurance bonds
• details of home, contents, car, mortgage or similar
policies.
Give details below
Go to next question
No
Yes
Attach the policy document and the latest
statement for each policy.
Name of insurance company
1
Policy number Surrender value
$
Your share
Partner’s
share
%%
Name of insurance company
2
Policy number Surrender value
$
Your share
Partner’s
share
%%
If you (and/or your partner) have more than
2 insurance policies, attach a separate sheet with details.
SA369.1409
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Year
Do you (and/or your partner) own, partly own or have a
financial interest in any motor vehicles, motor cycles or
trailers?
14
Give details below
Go to next question
No
Yes
Type of asset
(e.g. car)
1
Make (e.g. Ford)
Your share
Partner’s
share
%%
Current market value Amount owed
$$
Model
(e.g. Focus)
Do you (and/or your partner) own, partly own or have a
financial interest in any boats or caravans/motor homes?
15
Give details below
Go to next question
No
Yes
If you (and/or your partner) have more than 2 motor
vehicles, motor cycles or trailers, attach a separate sheet
with details.
If you (and/or your partner) have more than 2 boats,
caravans or motor homes, attach a separate sheet
with details.
Year
Type of asset
(e.g. car)
2
Make (e.g. Holden)
Your share
Partner’s
share
%%
Current market value Amount owed
$$
Model
(e.g. Astra)
Year
Type of asset
(e.g. boat)
1
Make (e.g. Quintrex)
Your share
Partner’s
share
%%
Current market value Amount owed
$$
Model
(e.g. Coastrunner)
Year
Type of asset
(e.g. caravan)
2
Make (e.g. Jayco)
Your share
Partner’s
share
%%
Current market value Amount owed
$$
Model
(e.g. Heritage)
Do NOT include a boat or caravan that is your
principal home.
SA369.1409
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Give details below of all accounts held by you (and/or your
partner) in banks, building societies or credit unions.
16
Name of bank,
building society or
credit union
Include savings accounts, cheque accounts, term
deposits, joint accounts, accounts you hold in trust or
under any other name, or money held in church or
charitable development funds.
Accounts and term deposits outside Australia should be
included, with the current balance in the type of currency
in which it is invested. We will convert this into Australian
dollars.
Do NOT include shares, managed investments or an
account used exclusively for funding from the National
Disability Insurance Scheme.
Attach proof of all account balances (e.g. ATM slip,
statements, passbooks). Copies can be provided.
1
Your share
Partner’s
share
%%
Account number
(this may not be
your card number)
Type of account
Balance of account
Currency if not AUD
$
Continued
If you (and/or your partner) have more than 5 accounts,
attach a separate sheet with details.
Name of bank,
building society or
credit union
2
Your share
Partner’s
share
%%
Account number
(this may not be
your card number)
Type of account
Balance of account
Currency if not AUD
$
Name of bank,
building society or
credit union
3
Your share
Partner’s
share
%%
Account number
(this may not be
your card number)
Type of account
Balance of account
Currency if not AUD
$
Name of bank,
building society or
credit union
4
Your share
Partner’s
share
%%
Account number
(this may not be
your card number)
Type of account
Balance of account
Currency if not AUD
$
Name of bank,
building society or
credit union
5
Your share
Partner’s
share
%%
Account number
(this may not be
your card number)
Type of account
Balance of account
Currency if not AUD
$
SA369.1409
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Do you (and/or your partner) have any bonds or
debentures?
17
Bonds refer to government and semi-government bonds.
Include:
• investments in and/or outside Australia
Bonds or debentures outside Australia should be
included, with the current balance in the type of currency
in which it is invested. We will convert this into Australian
dollars.
Do NOT include:
• friendly society bonds, funeral bonds or life insurance
bonds
• accommodation bonds for residing in an aged care
facility.
Give details below
Go to next question
No
Yes
Attach a document which gives details for
each bond or debenture.
Name of company
1
Current amount invested Currency if not AUD
Your share
Partner’s
share
%%
Type of investment
$
Name of company
2
Current amount invested Currency if not AUD
Your share
Partner’s
share
%%
Type of investment
$
Name of company
3
Current amount invested Currency if not AUD
Your share
Partner’s
share
%%
Type of investment
$
If you (and/or your partner) have more than 3 bonds or
debentures, attach a separate sheet with details.
Do you (and/or your partner) have money on loan to another
person or organisation?
18
Include all loans, whether they are made to family
members, other people or organisations or trusts.
Do NOT include loans to get accommodation in a hostel.
Give details below
Go to next question
No
Yes
Attach a document which gives details for
each loan (if available).
Who did you lend the money to?
1
Current balance of loan
Amount lent
$
Lent by you
Lent by your
partner
%%
Date lent
$
/ /
Who did you lend the money to?
2
Current balance of loan
Amount lent
$
Date lent
$
/ /
Who did you lend the money to?
3
Current balance of loan
Amount lent
$
Date lent
$
/ /
If you (and/or your partner) have more than 3 loans,
attach a separate sheet with details.
Lent by you
Lent by your
partner
%%
Lent by you
Lent by your
partner
%%
SA369.1409
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Do you (and/or your partner) own any shares, options,
rights, convertible notes or other securities LISTED on an
Australian Stock Exchange (e.g. ASX, NSX, APX or Chi-X) or
a stock exchange outside Australia?
19
Include shares traded in exempt stock markets.
Do NOT include managed investments.
Give details below
Go to next question
No
Yes
Attach the latest statement for each share
holding.
Name of company
1
Country if not Australia
ASX code (if known)
Your share
Partner’s
share
%%
Number of shares
or other securities
Name of company
2
Country if not Australia
ASX code (if known)
Your share
Partner’s
share
%%
Number of shares
or other securities
Name of company
3
Country if not Australia
ASX code (if known)
Your share
Partner’s
share
%%
Number of shares
or other securities
If you (and/or your partner) have more than 3 share
holdings, attach a separate sheet with details.
Do you (and/or your partner) own any shares, options or
rights in PUBLIC companies, NOT listed on a stock
exchange?
20
Do NOT include managed investments.
Give details below
Go to next question
No
Yes
Attach the latest statement detailing
your share holding for each company
(if available).
Name of company
1
Current market value
Type of shares
Your share
Partner’s
share
%%
Number of shares
$
Name of company
2
Current market value
Type of shares
Your share
Partner’s
share
%%
Number of shares
$
Name of company
3
Current market value
Type of shares
Your share
Partner’s
share
%%
Number of shares
$
Name of company
4
Current market value
Type of shares
Your share
Partner’s
share
%%
Number of shares
$
If you (and/or your partner) have more than 4 share
holdings, attach a separate sheet with details.
Margin loan balance
$
Margin loan balance
$
Margin loan balance
$
SA369.1409
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Do you (and/or your partner) have any managed
investments in and/or outside Australia?
21
Include:
• investment trusts
• personal investment plans
• life insurance bonds
• friendly society bonds.
Do NOT include:
• conventional life insurance policies
• funeral bonds, superannuation or rollover investments.
APIR code – is commonly used by fund managers to
identify individual financial products.
Give details below
Go to next question
No
Yes
Attach a document which gives details
(e.g. certificate with number of units or
account balance) for each investment.
Name of company
1
Name of product
(e.g. investment trust)
Type of product/option
(e.g. balanced, growth)
APIR code (if known)Number of units
Current market value Currency if not AUD
$
Your share
Partner’s
share
%%
Name of company
2
Name of product
(e.g. investment trust)
Type of product/option
(e.g. balanced, growth)
APIR code (if known)Number of units
Current market value Currency if not AUD
$
Your share
Partner’s
share
%%
If you (and/or your partner) have more than 2 managed
investments, attach a separate sheet with details.
22
Do you (and/or your partner) have any funeral bonds/
funeral investments, including a pre-paid funeral?
23
Have you (and/or your partner) a contract to have funeral
services provided for which an agreed sum has already
been paid to the provider or used to buy funeral bonds
assigned to the provider?
If you (and/or your partner) have more than 2 funeral
bonds/funeral investments, attach a separate sheet with
details.
Give details below
Go to 24
No
Yes
Name of company
1
Current value
as per latest statement
Name of product
Your share
Partner’s
share
%%$
APIR code
Purchase price incl.
instalments but not interest
Name of company
2
Current value
as per latest statement
Name of product
Your share
Partner’s
share
%%$
APIR code
Purchase price incl.
instalments but not interest
Go to next question
No
Yes
Attach a copy of each contract.
$
$
SA369.1409
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Please read this before answering the following question.
24
YOU should answer this question ONLY if you are over
age pension age or claiming Age Pension.
YOUR PARTNER should answer this question ONLY if
they are over age pension age or claiming Age Pension.
Owned by:
From 1 July 2017, the qualifying age for Age Pension will
increase from 65 years to 65 years and 6 months. The
qualifying age will then rise by 6 months every 2 years,
reaching 67 years by 1 July 2023. See table below.
Do you (or your partner) have any money invested in
superannuation where the fund is still in accumulation
phase and not paying a pension?
Include:
• superannuation funds such as retail, industry,
corporate or employer and public sector
• retirement savings accounts
• Self Managed Superannuation Funds (SMSF) and
Small APRA Funds (SAF) if the funds are complying.
Give details below
Go to next question
No
Yes
Attach the latest statements for retirement
savings accounts and superannuation
funds. If you have a SMSF or SAF, attach
the financial statement including income
tax return and member statement.
Name of institution/fund manager
1
Name of fund
Current market value
$
Date of joining/investment
/ /
You Your partner
Continued
If you (and/or your partner) have more than
3 superannuation investments, attach a separate sheet
with details.
Owned by:
Name of institution/fund manager
2
Name of fund
Current market value
$
Date of joining/investment
/ /
You Your partner
Owned by:
Name of institution/fund manager
3
Name of fund
Current market value
$
Date of joining/investment
/ /
You Your partner
1 July 1952 to
31 December 1953 65 years and 6 months
1 January 1954 to
30 June 1955 66 years
1 July 1955 to
31 December 1956 66 years and 6 months
From 1 January 1957 67 years
Qualifying age atDate of birth
SA369.1409
10 of 17
Do you (and/or your partner) have any money invested in,
or do you receive income from, any other investments not
declared elsewhere on this form?
26
Include:
• all investments from outside Australia (including
superannuation) not declared elsewhere on this form.
Do NOT include:
• income from real estate in or outside Australia, private
trusts, private companies or business
• social security payments
• an account used exclusively for funding from the
National Disability Insurance Scheme.
Give details below
Go to next question
No
Yes
Attach a document which gives details for
each investment.
Type of investment
1
Currency if not AUD
Name of organisation/company
Your share
Partner’s
share
%%
Current value
of investment
Income received
in last 12 months
Type of investment
2
Currency if not AUD
Name of organisation/company
Your share
Partner’s
share
%%
Income received
in last 12 months
If you (and/or your partner) have more than
2 investments, attach a separate sheet with details.
Current value
of investment
Give details below
Go to next question
No
Yes
You (and/or your partner) will need to
attach a
Details of income stream
product
form (SA330) or a similar
schedule, for each income stream
product. 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 our
website
www.humanservices.gov.au/forms or
call us on 132 300.
Do you (and/or your partner) receive income from any
income stream products?
If you (and/or your partner) have more than 2 income
stream products, attach a separate sheet with details.
Name of product provider/SMSF/SAF
1
Type of income stream
Product reference number
Please read this before answering the following question.
25
An income stream product is a regular series of
payments which may be made for a lifetime or a fixed
period by:
• a financial institution
• a retirement savings account
• a superannuation fund
• a Self Managed Superannuation Fund (SMSF)
• a Small APRA Fund (SAF)
.
Types of income streams include:
• account-based pension (also known as allocated
pension)
• market-linked pension (also known as term allocated
pension)
• annuities
• defined benefit pension (e.g. ComSuper pension, State
Super pension)
• superannuation pension (non-defined benefit).
Commencement date
/ /
Owned by: You Your partner
Name of product provider/SMSF/SAF
2
Type of income stream
Product reference number Commencement date
/ /
Owned by: You Your partner
SA369.1409
Do you (or your partner) receive payments from sources
other than Centrelink income support payments?
27
Give details below
Go to next question
No
Yes
Attach a letter or other document(s) that
shows the reference number and details
for each payment (other than payments
made by us).
Paid to:
Type of payment
1
Who pays it?
Reference number
(if known)
Date commenced
(if known)
/ /
You Your partner
Paid to:
Type of payment
2
Who pays it?
Reference number
(if known)
Date commenced
(if known)
/ /
You Your partner
If you (and/or your partner) receive more than
2 payments, attach a separate sheet with details.
Do you (and/or your partner) receive payments from an
authority or agency outside Australia?
28
Give details below
Go to next question
No
Yes
Attach a document from the issuing
authority or agency which gives details
including the amount in the foreign
currency (e.g. latest pension certificate)
for each payment.
Type of payment
1
Country which pays it?
Authority or agency which pays it?
Date commenced
(if known)
/ /
If you (and/or your partner) receive more than
2 payments from an authority or agency outside
Australia, attach a separate sheet with details.
Include pensions from other countries, benefits,
allowances, superannuation, compensation and war
related payments.
Note: You must include details of pensions, allowances
and other payments even if they are not taxable in the
country of payment.
Type of payment
2
Country which pays it?
Authority or agency which pays it?
Date commenced
(if known)
/ /
11 of 17
Paid to: You Your partner
Paid to: You Your partner
For example:
• a payment from Department of Veterans' Affairs (DVA),
or
• New Enterprise Incentive Scheme (NEIS) Allowance,
or
• Community Development Employment Projects (CDEP)
wages.
