Life Certificate
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AUS061.1402
Customer’s responsibilities
• You are required to have this certificate verified (see page 3) by one of the people listed below:
- notary public/advocate
- Justice of the Peace
- Australian official at an embassy,
consulate or high commission
- local social security authority
- priest or religious leader
- magistrate
- solicitor
- physician.
• official papers or documents which include a photograph of yourself must be presented
as identification. Suitable documents include:
- passport
- identification card
- other official government documents.
• any costs involved in getting this certificate verified will be your responsibility.
• if you fail to return this certificate within 6 weeks your pension may be stopped.
1 Your personal details
Family name
First given name
Date of birth
Centrelink Reference Number
Never married or lived with a partner
Married
Partnered
(living together in an opposite-sex or
same-sex relationship, including de facto)
Widowed
(previously partnered with an opposite-sex
or same-sex partner, including in a marriage,
registered or de facto relationship)
Date of marriage
Date you started living
together as a couple
Date of partner’s death
Life Certificate
Date of decree absolute
Date of separation
Divorced
Separated
(previously lived with an opposite-sex or
same-sex partner, including in a marriage,
registered or de facto relationship)
Sex Male Female
Registered relationship
(opposite-sex or same-sex relationship
registered under Australian state or territory law)
Date of registration
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3 Do you live in the same home as
your former partner?
No
Yes
To be completed by customer
Second given name
Title Mr Mrs Miss Ms Other
2 What is your CURRENT
relationship status?
We recognise both opposite-sex
and same-sex relationships. This
includes de facto relationships
and relationships registered under
Australian state or territory law. If
you and your same-sex partner
have married or had your
relationship registered outside
Australia, please indicate your
relationship as ‘partnered’ in this
list.
Select ONE option below that best
describes your current relationship
status.
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CLK0AUS061 1402
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AUS061.1402
Country
Contact phone number
I declare that:
I understand that: • giving false or misleading information is a serious offence.
• the information I have given in this form is complete and correct.
Your signature
Date
Signature of person signing
on behalf of the customer
Date
4 Contact details Address
6 Statement
If the customer is unable to sign due
to physical, psychiatric or intellectual
disability, or due to illiteracy, another
person may sign on their behalf by
completing question 7 (below).
7 Detals of person signing on
behalf of the customer (if
customer is unable to sign)
Please refer to Privacy and your
personal information at question 5.
Name of person
Address
Relationship to customer
Contact phone number
Country
If the customer wants to arrange for another person or organisation to enquire or act on his/her behalf
when dealing with the Department of Human Services, please tick this box and we will send you
the required form.
Please attach evidence
of the customer’s
inability to sign this form
(e.g. legal or medical
documents, Social
Worker report).
Country
Area
code
Country
Area
code
You must now take this form to an authorised person to confirm your identity (see below).
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5 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.
Day Month Year
()()
AUS061.1402
Country
Contact phone number
I declare that:
I understand that: • giving false or misleading information is a serious offence.
• personal information is protected by Australian law.
• I am satisfied as to the identity of the customer.
Signature of
authorised person
Date
Official stamp or seal
of authorised person
9 Contact details Address
11 Statement
Please refer to Privacy and your
personal information at question 5.
10 Documentation provided for
identification of the customer
Country
Area
code
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To be completed by
authorised person
8 Details of authorised person Title
Given name(s)
Family name
Mr Mrs Miss Ms Other
• As a person authorised to verify the identity of a customer, it is essential that you sight adequate
identification to satisfy yourself as to the person’s true identity.
• Satisfactory identification would be official papers or documents that include a photograph of the
person. Suitable documents include:
- passport
- identification card
- other official government documents.
• If a person is unable to provide any photographic identification, you should be certain of their
identity from other sources before verifying their identity.
• The person’s signature should be certified from official documents.
• To verify the person’s identity complete the details below.
• This form must be signed and stamped with your official stamp or seal or an official document
provided that confirms that the customer is alive.
