Fillable Printable Mobility Allowance Claim for Advance Payment - Australia
Fillable Printable Mobility Allowance Claim for Advance Payment - Australia
Mobility Allowance Claim for Advance Payment - Australia
Mobility Allowance
Claim for advance payment
Use this form to claim an advance payment of Mobility Allowance.
Purpose of this form
Go to our website atwww.humanservices.gov.au/mobilityallowance or call us on 132 717
or visit one of our Service Centres.
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.
For more information
Check that you have answered all the questions you need to answer and that you have
signed and dated this form.
Return this form online or to one of our Service Centres.
For more information on how to access Online Services or how to lodge documents
online, go to
www.humanservices.gov.au/submitdocumentsonline
Returning your form
Filling in this form
If you need an interpreter or translation of any documents for our business, we can
arrange this for you free of charge.
Interpreters and
translations
TTY service Freecall™ 1800 810 586. A TTY phone is required to use this service.
If you have a hearing or
speech impairment
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MA007T.1403
•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.
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Your name
Other
Family name
1
First given name
Second given name
MsMissMrsMr
Your permanent address
Postcode
2
Your postal address (if different to above)
3
4
Postcode
Your contact details
Home phone number
Is this a silent number?
Mobile phone number
( )
NoYes
Paid work
Training course
Voluntary work
Life Skills training (e.g. managing money)
Looking for work
Your Centrelink Reference Number (if known)
5
Which of the following are you doing:
Tick more than one if applicable
7
Vocational rehabilitation activities
No
Yes
Details of the organisation(s) you are doing the above
activities with.
8
Name of organisation
Address
Postcode
Phone number
What type of activity are you doing with this organisation
(e.g. work, training)?
How many hours per week are you doing this?
hours per week
Are these hours the same each week?
Go to 11
Go to next question
How many hours do you spend over a 2 week period doing
the above activities?
9
How many hours do you spend over a 4 week period doing
the above activities?
10
hours
hours
( )
Are you receiving a funded package of support from the
National Disability Insurance Scheme?
6
No
You cannot receive an advance payment of
Mobility Allowance. For more information
call us on 132 717.
You will need to sign the statement at
question 18 and return this form to us.
Yes
Go to next question
Go to 17
If you are not sure you can call the National Disability
Insurance Agency on 1800 800 110.
CLK0MA007T 1403
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If you are eligible for Mobility Allowance, you can receive
an advance on your payments. The advance equals 13
fortnightly payments.
It is only paid once every 12 months and any part of the
advance cannot be returned in order to resume
fortnightly payments. When the 6 month advance period
ends, you automatically go back to fortnightly payments.
Did someone help you complete this form?
Statement
15
16
Name of person who helped you
18
I declare that:
•the information provided in this form is complete and
correct.
I understand that:
•if someone has helped me complete this form, the
Australian Government Department of Human Services
may contact them to clarify details provided.
•giving false or misleading information is a serious
offence.
•the Australian Government Department of Human
Services can make relevant enquiries to make sure I
receive my correct entitlement.
Would you like to receive a 6 month lump sum payment?
Why did you need help to complete this form?
No
Yes
Go to next question
Give details below
No
Yes
Your signature
Date
/ /
When do you expect to finish?
Will an
y of the activities you selected in question 7 continue
for the next 6 months?
11
Go to next question
12
You will not be eligible for an advance
payment of Mobility Allowance. For more
information call us on 132 717.
Ongoing
No
Yes
/ /
Do you expect to leave Australia in the next 6 months (even
for a short holiday)?
When do you expect to leave?
13
Go to 15
Go to next question
14
No
Yes
/ /
17
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.
IMPORTANT INFORMATION
