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 at www.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

First given name

Second given name

MsMissMrsMr

Your permanent address

Postcode

Your postal address (if different to above)

Postcode

Your contact details

Home phone number

Is this a silent number?

Mobile phone number

( )

No Yes

Paid work

Training course

Voluntary work

Life Skills training (e.g. managing money)

Looking for work

Your Centrelink Reference Number (if known)

Which of the following are you doing:

Tick more than one if applicable

Vocational rehabilitation activities

Yes

Details of the organisation(s) you are doing the above

activities with.

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?

How many hours do you spend over a 4 week period doing

the above activities?

hours

( )

Are you receiving a funded package of support from the

National Disability Insurance Scheme?

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.

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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

Name of person who helped you

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?

Yes

Go to next question

Give details below

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?

Go to next question

You will not be eligible for an advance

payment of Mobility Allowance. For more

information call us on 132 717.

Ongoing

Yes

/ /

Do you expect to leave Australia in the next 6 months (even

for a short holiday)?

When do you expect to leave?

Go to 15

Go to next question

Yes

/ /

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