Fillable Printable The Pension Service Claim Sample Form
Fillable Printable The Pension Service Claim Sample Form
The Pension Service Claim Sample Form
D648 11/14 P1 of 12
Claim for Service Pension or
Income Support Supplement
Part B – Income and Assets
Claimant
Partner
Are dependent children included in this claim?
Two part claim
This is
Part B
of a two part claim form. To avoid delays in
processing your claim, please ensure both
Part B
and
Part A
are lodged together.
Completing this form
If you want to
know more
about the different types of income and
assets, please refer to the booklet About Claiming Service Pension or
About Claiming Income Support Supplement.
If your income and assets are complex, you may choose to use (at your
own expense) an accountant or financial adviser to help you complete
this form, but you (and your partner) must sign it.
If you
need more space
to answer questions, please provide an
attachment with the required details.
Please
tick
the appropriate boxes.
Please use
black
or
blue pen
.
If you have a partner
You must provide details of your partner’s income and assets in this
form, even if:
•
your partner is not claiming; or
•
your partner is already in receipt of service pension or income
support supplement.
You are asked to show whether you or your partner own an income or
asset item. Tick the ‘You’ box or the ‘Partner’ box. If it is owned jointly,
tick both boxes.
Privacy notice
Your personal information is protected by law, including the Privacy Act
1988. Your personal information may be collected by the Department of
Veterans’ Affairs (DVA) for the delivery of government programs for war
veterans, members of the Australian Defence Force, members of the
Australian Federal Police and their dependants.
Family name Date of birth File number (if known)Given name(s)
No Yes
$
$
$
$
SECTION
A Income and assets
D648 11/14 P2 of 12
Bank accounts
1 Give details of all your (and/or your partner’s)
bank, building society and credit union accounts
Include: term deposits, joint accounts, accounts you
hold under any other name or money held in church
or charitable development funds.
Include details of the account your pension will be
paid into.
Do NOT include bonds or debentures. You will be
asked about these in a later question.
Account number or
Name of institution Name(s) in which account is held term deposit number Type of account Current balance
If you have money held in a church or charity account,
please attach a statement or document confirming details.
Yes
No
Cash holdings
2 Do you (and/or your partner) have cash holdings
totalling more than $2,000?
This does NOT include cash you have for shopping
and other day-to-day expenses.
Cash holdings means notes and coins you have in a
safety deposit box, or you are holding instead of
putting it into a bank account, or someone else is
looking after for you.
Amount owned by you
Amount owned by your partner
Yes
No
Shares
3 Do you (and/or your partner) own any shares,
options, rights, convertible notes or other
securities?
This includes listed and unlisted shares.
It includes shares traded in Australian and overseas
markets, and in exempt stock markets.
Give details
Total number Owned by:
Name of company Type of share of shares You Partner
Please attach a certified copy of the latest statement or
schedule detailing your share holding for each company.
SECTION
A continued
INCOME AND ASSETS
D648 11/14 P3 of 12
Yes
No
Bonds/debentures
4
Do you (and/or your partner) have any
bonds or debentures?
This includes bonds and debentures offered
by finance companies, public companies,
Government or Government business
enterprises, banks and financial institutions
in Australia and overseas.
Do NOT include friendly society bonds or
insurance bonds. You will be asked about
these in a later question.
Give details
Money invested with Certificate or Series Number Invested in name(s) of Current balance
Yes
No
Money on loan
5 Do you (and/or your partner) have money
on loan to anyone (including family
members) or money on loan to a private
trust or company?
Give details
Balance Lent by:
Name of the person to whom the money is loaned Date lent outstanding
You Partner
For each loan, please attach a certified copy
of a document which gives details.
Managed investments
6 Do you (and/or your partner) have any
managed investments?
Managed investments include investment
trusts, personal investment plans, insurance
bonds and friendly society bonds.
Do NOT include any life insurance policies.
Do NOT include superannuation or rollover
investments. You will be asked about these
in a later question.
Do NOT include bonds and debentures (you
should have listed these at Question 4).
Give details
Owned by:
Investment product
You Partner
For each managed investment owned by you (and/or your partner),
you
must
attach a certified copy of the latest documents which provide
details (e.g. certificate with number of units or account balance).
Yes
No
SECTION
A continued
INCOME AND ASSETS
D648 11/14 P4 of 12
Yes
No
7
Do you (and/or your partner) have any money
in a superannuation fund where your fund is
in the accumulation phase and not paying
you a pension?
Superannuation funds include retail, industry
corporate, employer or public sector funds and
retirement savings accounts.
Do NOT include a self managed superannuation
fund. You will be asked about this in another question.
You must attach a certified copy of the latest statement for
each fund.
Give details
Owned by:
Name of institution/fund manager Investment product
You Partner
ComSuper, DFRB and any other defined benefit superannuation payments
8 Do you (and/or your partner) receive or are
you entitled to receive or are you presently
applying for superannuation defined benefit
income, pension or disability payments?
(Examples of defined benefit superannuation
fund payments include ComSuper pension,
Defence Force Retirement Benefits pension,
Military Super pension, State Super pension,
bank employee super).
Give details
Please attach your latest statement of benefit from the paying
authority. If your payment includes a tax free component, you
must also provide evidence of the amount from the paying
authority. A tax free component may be allowed as a
deduction against your gross payment.
Paid to:
Name of superannuation payment Start date Reference number
You Partner
Income streams other than defined benefit superannuation payments
9 Do you (or your partner) receive income from
an income stream?
An income stream is a regular series of
payments which may be made for a lifetime or
fixed period by:
• a financial institution
• a superannuation fund
• a retirement savings account.
Give details
Paid to:
Name of product provider Type of income stream Start date Product reference number
You Partner
Types of income streams include:
• account-based pension/allocated pension
• transition to retirement pension
• market linked pension/term allocated pension
• immediate annuity/account-based annuity
• superannuation pension (non-defined benefit).
Please attach a certified copy of documents which provide the latest details of each income stream — your provider
should be able to provide you with an ‘income stream schedule’ for each income stream product.
Yes
No
Yes
No
D648 11/14 P5 of 12
Yes
No
SECTION
A continued
INCOME AND ASSETS
Self managed superannuation funds
10 Are you (and/or your partner) a member of
a self managed superannuation fund
(SMSF) or a small APRA fund (SAF)?
These are superannuation funds you have
set up yourself ( also referred to as Do It
Yourself or DIY Funds).
Please attach a copy of the latest tax return for the
fund and the member statement.
Please attach a copy of documents which
provide the latest details of each income stream
and an ‘income stream schedule’ for each
income stream product.
Do you (and/or your partner) draw an income stream from
the SMSF or SAF in the form of an account-based or
allocated pension, transition to retirement pension, market
linked pension, lifetime or life expectancy pension/annuity?
Please attach full documentation in
respect of SMSF or SAF
investments. Contact your nearest
DVA office if you require more
information about what should be
provided.
Please attach a copy of the latest council
rates notice for each property.
Does the SMSF or SAF hold any real estate?
Gifts
In the last 5 years have you (and/or your
partner) given away, sold for less than
their value, or surrendered a right to, any
cash, assets, property or income?
This includes forgiven loans and shares in
private companies.
Give details
What you gave away or sold for less than its Gift made by:
value (e.g. money, car, second home, land, farm)
Date given or sold What it was worth What you got for it You Partner
12 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?
Include all overseas investments not declared
elsewhere on this form.
Do NOT include real estate in Australia, private
trusts, private companies or business. You will
be asked about these in later questions.
Other investments
Give details
For each investment, please attach a certified
copy of a document which gives details.
Current value Income received Owned by:
Type of investment Name of organisation/company of investment in last 12 months
You Partner
Yes
No
11
Employment
13
Do you or your partner CURRENTLY
receive any income from work?
Do NOT include income from
self-employment. You will be asked
about this later in the form.
YOU YOUR PARTNER
For each employment, attach a completed Employment Report
form (D518).
No Yes No Yes
Yes
No
Yes
No
Yes
No
SECTION
A continued
INCOME AND ASSETS
D648 11/14 P6 of 12
YesNo
14
In the last 12 months, have you or your
partner stopped working for any
employers?
Including self-employment.
YOU YOUR PARTNER
Date ceased
Date ceased
For each employer, please attach the Employment Separation
Certificate or complete the Retirement Benefits form (D531).
Income from an agency outside Australia
15 Do you (or your partner) receive income
from an agency outside Australia?
This includes overseas pensions (e.g. British
social security, armed forces, public service
and war pensions), benefits, allowances,
superannuation, compensation and war
related payments.
Please note: If you are eligible for an
overseas payment but don’t receive it, then
you must apply and advise DVA when you
receive it.
Give details
Paid to:
Type of payment Country who pays it
You Partner
For each payment, attach a certified copy of the latest document,
which shows the payment amount in the foreign currency and the
frequency of the payment. The document should also provide a
breakdown of the amounts included (e.g. for British social security
pension - attendance allowance, basic pension, graduated
retirement benefit etc.).
The document must be in English. If necessary, provide a
translation by an accredited translator.
Yes
No
Money from boarders or lodgers
16 Do you (and/or your partner) receive
money from any boarders or lodgers living
with you?
This includes boarders or lodgers who live
with you or in accommodation at the property
you live in (e.g. granny flat).
Do NOT include immediate family members
(son, daughter, parent).
Give details
Number of Amount paid for
Relationship to you meals you board or lodging Date boarder or Paid to:
Name of boarder/lodger
(e.g. friend, nephew) provide each day each fortnight lodger started paying
You Partner
Yes
No
No
Yes
Other payments
17 Do you (or your partner) receive any
payments from any other sources?
Other sources include:
• gratuities
• payment in kind, such as non-monetary
payments for services
• income from an estate
• any other income you have not included
elsewhere on this form.
For each type of payment, attach a certified copy of a
document which gives details.
Yes
No
Give details
Paid to:
Type of payment
Who pays it?
You Partner
SECTION
A continued
INCOME AND ASSETS
D648 11/14 P7 of 12
Yes
No
Vehicles
18 Do you (and/or your partner) own any motor
vehicles, boats, caravans or trailers?
Do NOT include a boat or caravan you live in, or
any farming or business vehicles.
Give details
Owned by:
Make (e.g. Ford) Model (e.g. Laser) Year Resale value Amount owing
You Partner
Life insurance policies
19 Do you (and/or your partner) have an
insurance policy that can be cashed in?
Do NOT include details of insurance bonds or
friendly society bonds in this question. You
should have given details of these in Question 6.
Give details
Owned by:
Name of insurance company Policy number Surrender value
You Partner
Other assets
20
Do you (and/or your partner) have any other
assets which you have not already told us
about?
Include valuable or collectible items such as
jewellery, antiques or bullion that are not included in
your Household contents value at Question 21
Give details
Current
Owned by:
Description of asset
market value
Amount owing
You Partner
Yes
No
Yes
No
Household contents
Household contents include all usual furniture such as soft furnishings (e.g. curtains), electrical appliances other than
fixtures such as stoves and built-in items. Personal effects include jewellery for personal use and hobby collections (e.g.
stamps, coins). The net market value of your household contents and personal effects is what you would get if you sold
them on the open market (less any debt or encumbrances). It is not the replacement or insured value.
$10,000 will be held as the value of
your contents and personal effects
What is the net market value of
your (and your partner’s) household
contents and personal effects?
$
21 Do you wish to declare a net market value
(resale value) for your household contents
and personal effects?
Yes
No
Go to question 28
SECTION
A continued
INCOME AND ASSETS
D648 11/14 P8 of 12
Leaving your home
If you leave your home and do not receive income in respect of it, your pension will not be affected for up to:
• 12 months - if you have left your home temporarily; or
• 24 months - if you have been given an extension of time by DVA to acquire your home; or
• 2 years - while you receive care or provide care.
While you are in residential aged care, paying an accommodation charge or an accommodation bond wholly or partially by
periodic instalment, and renting out your former home, the value of your home and the rent received will not affect your pension.
If you leave your home because:
• it was sold; or
• it was lost or damaged (including by a disaster)
and you intend to acquire a new home, or repair the old home, you can continue to be considered a homeowner for up to 12
months.
In these situations, the sale or insurance/compensation proceeds that you intend to use to acquire the home are also
disregarded from the assets test for up to 12 months. The time period can be extended for up to an additional 12 months, if you
are experiencing delays in acquiring your home.
22 Have you sold your home
within the last 2 years?
Do you intend to use part or all of the home sale proceeds to buy or build a new
home?
Please attach documents providing details of the home sale (such as a
solicitor’s settlement letter)
23 Do you own your own home
but you and/or your partner
live somewhere else?
24 Who has left your home?
25
Have you and/or your
partner left your home:
When do you and/or your partner expect to
return to your home?
Is the temporary absence because your home was lost or damaged?
You may be contacted by DVA to request further
details
26 Is the home you left:
Occupied rent free
Occupied by you or your partner
Occupied by carer of other family member(s) (e.g. dependent child)
Left vacant
How much rent do you receive?
$
What date was the property let?
What is the balance of the mortgage owing (if any)?
What is the interest payable on the mortgage?
Is the rental money being used to pay for accommodation
charges for you and/or your partner in an aged care facility?
Yes
No
Let
Please attach mortgage contract or other document showing the balance of the
mortgage, tax returns (if you have them) and a list of the expenses involved in
letting the property (e.g. rates, agent’s fees, taxes, repairs, insurance).
Other—please specify
Permanently
Temporarily
No Yes
You Your partner You and your partner
per fortnight
%
YesNo
Yes
No
Yes
No
SECTION
A continued
INCOME AND ASSETS
D648 11/14 P9 of 12
27 Have you and/or your partner moved
in with someone to provide care or to
be cared for?
Provide care Name of the person cared for
Be cared for Name of the care provider
Date you and/or your partner moved in to
provide care/be cared for?
How long will you and/or your partner be staying?
Long term or permanently
Short term or for respite care When do you and/or your
partner expect to leave?
Yes
No
Go to question
28
Please attach evidence of the need for a substantial level of
care (such as a doctor’s certificate).
Yes
No
Maintenance paid to a former partner
28 Do you (and/or your partner) pay
maintenance to a former partner?
Do NOT include maintenance paid for
any children.
How much per fortnight
Attach a certified copy of the deed or court agreement, or
other document which shows it is legally enforceable.
You pay Partner pays
Real estate details
29 If you own the home you live in (this
includes paying it off), does it stand
on a property larger than 2 hectares
(5 acres)?
Please complete and attach a Farm / Hobby Farm form
(D526), then go
30 Please tick the box which describes
the use of your property
PRIVATE AND
DOMESTIC
PURPOSES
If the property is on more than one title,
please complete and attach a Real
Estate form (D524) for each title other
than the title of your principal home.
COMMERCIAL USE
Please complete and attach a
Farm/Hobby Farm form (D526).
31 Do you (and/or your partner) own or
have an interest in any real estate in
Australia or overseas?
Do NOT include:
• your home;
• real estate owned or held by a
business, private company or
private trust – you will be asked
about these in a later question.
Yes
No
to Question
Yes
No
Please complete and attach a Real Estate form (D524) for
each property. In this form, you are asked to provide a
number of other documents such as a certified copy of your
last income tax return.
30.
SECTION
A continued
INCOME AND ASSETS
D648 11/14 P10 of 12
YesNo
Compensation and damages
32
Have you (and/or your partner)
received or are you receiving
compensation in relation to service
with the Australian Defence Force?
This includes compensation under the
Safety, Rehabilitation and Compensation
Act 1988 (SRCA), Defence Act 1903 and
the Military Rehabilitation and
Compensation Act 2004 (MRCA).
Type of payment
33 Have you (and/or your partner)
received or are you receiving or able
to claim any other compensation,
insurance or damages as a result of
injury, illness or accident?
This includes salary continuance,
income protection payments and Dust
Diseases Board payments. Claim may
be for:
• accident at work;
• work related illness;
• motor vehicle accident; or
• public liability.
Please complete and attach a Compensation form (D541)
for each injury, illness or accident.
Private company/private trust/business
34 Are you or have you (and/or your
partner) been involved in a private
trust in the last 5 years?
You may be, or have been a trustee,
an appointor or a beneficiary.
You may have made a loan to a
private trust, made a gift of cash,
assets or property to a private trust in
the last 5 years, relinquished control of
a private trust, a private annuity, a life
interest, or an interest in a deceased
estate.
Please complete and attach the Private Trust form (D601).
A separate form must be used for each trust.
If you do not have this form or you require additional forms,
contact DVA.
Have you or your partner ever contributed to a Special
Disability Trust?
Please complete and attach the Special
Disability Trust form (D9059). A separate
form must be used for each trust.
If you do not have this form or you require
additional forms, contact DVA.
36
Are you (and/or your partner)
involved in any other type of
business (this includes a farm)?
As a:
• sole trader;
• partnership; or
• subcontractor.
35 Are you or have you (and/or your
partner) been involved in a private
company in the last 5 years?
You may be, or have been a director
or a shareholder.
You may have made a loan to a
private company, transferred shares in
a private company, or made a gift of
cash, assets or property to a private
company.
Please complete and attach the Private Company form
(D600). A separate form must be used for each company.
If you do not have this form or you require additional forms,
contact DVA.
Please complete and attach the Details of Business
form (D525) or the Farm / Hobby Farm form (D526).
A separate form must be used for each business. In
these forms, you are asked to provide a number of
other documents such as a certified copy of your last
income tax return.
If you do not have this form or you require additional
forms, contact DVA.
Yes
No
Yes
No
Yes
No
YesNo
Yes
No
SECTION
B Attachment checklist
D648 11/14 P11 of 12
You must attach documents as evidence of your answers to some of the questions.
You must provide
certified copies
(see ‘Who can certify copies of documents’ in the
booklet About Claiming Service Pension or About Claiming Income Support
Supplement), or
original
documents can be sighted and verified by a DVA officer.
If any of your documents are in a language other than English, you must also provide
translations into English by an accredited translator.
If you do not have a form that you need, contact your nearest DVA or VAN office.
Use this checklist to make sure you have attached all the relevant documents.
Question
1
For money held in a church or charity account, a statement or document
3
Latest statement or schedule detailing your share holdings
5
Loan documents
6
Managed investment certificates or similar documents
7
8
Latest statement of benefits document from the paying authority
9
Latest ‘income stream schedule’ for each income stream product
Latest statements for superannuation fund investments
10
Tax returns and member statements for SMSF and SAF funds; latest ‘income
stream schedule’ for each income stream product; and latest council rates notices
for real estate held by those funds
12
Documents with details of investments
13
Attach Employment Report form (D518)
14
Attach Employment Separation Certificate or Retirement Benefits form (D531)
15
Documents with details of overseas agency payments
17
Documents with details of other payments
22
Documents providing details of the home sale
26
Mortgage contract, tax returns and list of letting expenses
27
Evidence of the need for a substantial level of care
28
Deed, court agreement or other document
29
Attach Farm /Hobby Farm form (D526)
30
Attach Real Estate form (D524) or Farm/Hobby Farm form (D526)
31
Attach Real Estate form (D524)
33
Attach Compensation form (D541)
34
Attach Private Trust form (D601)
34
Attach Special Disability Trust form (D9059)
35
Attach Private Company form (D600)
36
Attach Business details form (D525) or Farm / Hobby Farm form
(D526)
Please complete SECTIONS C and D on the next page
