Assistance for Isolated Children (AIC) Additional Information Purpose of this form

Assistance for Isolated Children (AIC)
Additional Information
Purpose of this form
The purpose of Assistance for Isolated Children (AIC) is to provide assistance to geographically
isolated families in recognition that families living in areas without access to appropriate
schools incur extra education costs.
Who should complete
this form
This form is to be completed by the AIC applicant.
Definition of a partner
For the Australian Government Department of Human Services purposes a person is
considered to be your partner if you and the person are living together, or usually
live together, and are:
• married, or
• in a registered relationship (opposite-sex or same-sex), or
• in a de facto relationship (opposite-sex or same-sex).
We consider a person to be in a de facto relationship from the time they commence living
with another person as a member of a couple.
We recognise all couples, opposite-sex and same-sex.
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
my.gov.au
www.
For more information
Go to our website humanservices.gov.au/isolatedchildren or call us on 132 318
or visit one of our Service Centres.
www.
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
TTY service Freecall™ 1800 810 586. A TTY phone is required to use this service.
Interpreters and
translations
If you need an interpreter or translation of any documents for our business, we can
arrange this for you free of charge.
Filling in this form
•
•
•
•
Please use black or blue pen.
Print in BLOCK LETTERS.
Mark boxes like this with a or .
Go to 5 skip to the question number shown. You do not
Where you see a box like this
need to answer the questions in between.
Please keep these Notes (pages 1 and 2) for your information.
SY041.1407
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Returning your form
Check that you have answered all the questions you need to answer and that you have
signed and dated this form.
If you return required documents (and your claim form):
• online - you can submit your documents online if you are registered for online services.
• by post – we will sight and record your documents, which may include copying, and
return the originals to you by registered post.
• in person – we will sight and record your documents, which may include copying, and
return the originals to you.
Return this form and any additional documents to one of our Service Centres or post it
directly to:
Department of Human Services
Student Services
Reply Paid 7804
CANBERRA BC ACT 2610
If you are lodging documents online, to establish your identity, we may still require you
to attend an office to provide orginial documents. For more information on how to lodge
documents online, go to humanservices.gov.au/submitdocumentsonline
www.
To lodge by fax
Fax to 1300 786 102
An important note for
applicants
Any AIC debt will usually be recovered by reducing any remaining payments you may
receive. If you are no longer receiving AIC, you will have to arrange to repay the debt directly
to Centrelink. The debt is always recovered from the applicant, not from the agent/student
who receives AIC.
Disclosure of Information
The Freedom of Information Act 1982 allows the disclosure of information directly to the
individual concerned.
Please keep these Notes (pages 1 and 2) for your information.
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Assistance for Isolated Children (AIC)
Additional Information
3
OFFICE USE ONLY
Centrelink Reference Number – Applicant
Your date of birth
/
Centrelink Reference Number – Student
Logon ID
4
/
Has your relationship status changed since 1 January in the year
of study?
No
Go to next question
Yes
Date the change occurred
Who should complete this form?
/
/
This form is to be completed by the AIC applicant.
5
Which questions should you complete?
You may not need to complete ALL questions in this form.
We recognise both opposite-sex and same-sex relationships.
This includes de facto relationships and relationships
registered under state or territory law.
• You must complete:
– Applicant details (questions 1 to 3)
– Student details (questions 8 to 10)
– The statement (question 53 or 54).
Select ONE option below that best describes your current
relationship status.
What is your CURRENT relationship status?
• You must also complete the following:
1
Go to 6
Applicant details (question(s)
)
Married
Education details (question(s)
)
Registered relationship
Living arrangement details (question(s)
)
Distance details (question(s)
)
(opposite-sex or same-sex relationship
registered under state or territory law)
Parental income details (question(s)
)
Partnered
Dependent children details (question(s)
)
Payment details (question(s)
)
(living together in an opposite-sex or
same-sex relationship, including de facto)
Tax file number details (question(s)
)
Is the applicant an organisation?
No
Go to next question
Yes
Give the organisation name
Mrs
Miss
Ms
Go to 8
Divorced
Go to 8
Widowed
(previously partnered with an opposite-sex or
same-sex partner, including in a marriage,
registered or de facto relationship)
Go to 8
Never married or lived with a partner
Go to 8
Other
Family name
First given name
Second given name
CLK0SY041 1407
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Go to 6
(previously lived with an opposite-sex or
same-sex partner, including in a marriage,
registered or de facto relationship)
Your name
Mr
Go to 6
Separated
Go to 8
2
Please read this before you answer this question.
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6
12 Give details of the school/institution, year and level of study the
Your partner’s name
Mr
Mrs
Miss
Ms
student is enrolled with/will enrol with in the year of study.
Other
Name of school/institution
Family name
First given name
Address of school/institution
Second given name
Postcode
7
Your partner’s date of birth
/
8
Grade or year (e.g. 1st grade, Year 10, 1st year)
/
Level:
Student’s name
Mr
Mrs
Miss
Ms
Other
Family name
Go to next question
ungraded
primary
Go to next question
secondary
Go to next question
tertiary
Give details below
Exact course title (e.g. Certificate of Office Studies)
First given name
Second given name
Course code number
9
Student’s date of birth
/
/
13 Will/did the student study full-time at the school/institution
nominated in question 12 for the whole study year?
No
10 What year are you claiming AIC for?
Period of full-time study
From
/
/
To
/
/
Please give reason
11 Please read this before answering the following question.
Questions 12 and 13 in this form are about the student’s
education details.
Refer to Which questions should you complete? on page 3 of
this form and the letter sent with this form.
Yes
Have you been asked to provide education details?
No
Go to 14
Yes
Go to next question
Go to next question
14 Please read this before answering the following question.
Questions 15 to 26 in this form are about the student’s living
arrangements.
Refer to Which questions should you complete? on page 3 of
this form and the letter sent with this form.
Have you been asked to provide living arrangement details?
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No
Go to 27
Yes
Go to next question
23 Will/did any other dependent children live in the second home
15 Tick the box which best describes the student’s living
arrangements during the school term.
and attend school daily or study by distance education in the
year of study?
Go to next question
Boarding at a private residence
Boarding at a residential institution
(e.g. boarding school or hostel)
No
Go to next question
Go to 17
Yes
Give details below
Living at a second home
maintained by the family
Go to 20
1 Family name
16 What is the name of the person providing board and the
First given name
relationship between this person and the student?
Name of person providing board
Date of birth
/
/
Relationship to student
2 Family name
Go to 18
17 What is the name of the institution where the student is/will be
First given name
boarding?
Date of birth
/
18 How many nights per week does/will the student board?
/
3 Family name
First given name
19 How much are the boarding fees paid for the student?
Do not include tuition fees paid to the school.
Date of birth
$
per year
/
/
If you have more than 3 dependent children, attach a separate
sheet with details.
20 Give the address details of the board location or second family
home.
24 Who is/will be living with the student at the second home?
You (the person named in question 2)
Go to next question
Your partner (named in question 6)
Go to next question
Both you and your partner
Go to next question
Postcode
21 Will the student be living at the location given in question 20 for
the full school year?
No
Period
From
To
/
/
/
/
/
/
/
/
Relationship to student
25 Will/did you (or your partner) receive Australian Government
housing assistance (e.g. Rent Assistance from Centrelink) for the
second family home address during the year of study?
Go to next question
22 Is the address in question 20 a second family home?
No
Go to 27
Yes
Go to next question
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Give details below
Name of person
If more than 2 periods, attach a separate sheet
with details.
Yes
Another person
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No
Go to next question
Yes
Type of assistance
26 Have you (or your partner) received, or will you (or your partner)
32 What is the distance from the principal family home to the
receive, First Home Owners Grant for the home/property being
claimed as your second home?
nearest transport pick-up point (e.g. bus stop), going to the state
school (named in question 28), by the shortest practicable route?
No
This includes transport which would be made available on
request.
Yes
Give distance to the nearest tenth of a kilometre
27 Please read this before answering the following question.
Questions 28 to 34 in this form are about the distance between
the nearest state school and principal family home.
Refer to Which questions should you complete? on page 3 of
this form and the letter sent with this form.
•
33 What is the distance from the transport pick-up point to the state
school (named in question 29), by the transport service route?
Give distance to the nearest tenth of a kilometre
Have you been asked to provide distance details?
No
Go to 35
Yes
Go to next question
kms
•
kms
34 How long does a return journey by public, private or school
transport take from the principal family home to the state school
(named in question 29)?
28 Give the name(s) and address(es) of the state school(s) nearest
to the principal family home which offer tuition at the student’s
level.
If there is more than one state school within 56 kms, give
details of the school with a transport pick-up point nearest to
the principal family home.
Where there is more than one state school, also attach a copy
of a scale map of the area showing the location of each school,
any bus pick-up points and school bus routes.
Refer to Reason for applying for AIC – Geographic Isolation
Rules in the booklet Information you need to know about
your claim for Assistance for Isolated Children (AIC).
hours
35 Please read this before answering the following question.
Questions 36 to 39 in this form are about parental income.
Refer to Which questions should you complete? on page 3 of
this form and the letter sent with this form.
Have you been asked to provide parental income details?
Name of school
Address of school (not PO Box number)
to the state school (named in question 28) by the shortest
practicable route?
You may be asked to provide evidence to confirm the distances
provided below.
Give distance to the nearest tenth of a kilometre
Go to 35
Go to next question
SY041.1407
Yes
Give details below
/
Go to 42
This includes transport which would be made available on
request.
Go to 34
Go to next question
Centrelink Reference Number/
Department of Veterans’ Affairs number
question 28)?
No
No
Type of assistance
31 Is there a transport service to the state school (named in
Yes
Go to next question
/
30 Is the distance stated in question 29, 56 kms or greater?
Yes
Yes
Date payments started
kms
Go to next question
Go to 40
of the following?
• A pension, benefit, allowance or payment from us.
• An income and assets tested pension from the Department of
Veterans’ Affairs.
• Farm Household Allowance.
• Community Development Employment Projects (CDEP) wages.
29 What is the distance one way from the principal family home
No
No
36 Other than Family Tax Benefit do you (or your partner) receive any
Postcode
•
minutes
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37 Do you (or your partner) have a current Health Care Card
39 Give the total of any fringe benefits shown on any payment
from us?
Not a card held on behalf of a child eligible for Carer Allowance
or a card held by a person receiving Mobility Allowance.
No
Go to next question
Yes
Dates on card
From
/
summaries for the Base Tax Year.
Your partner
You
$
You must attach proof of your (and your partner’s)
income.
To
/
$
/
/
40 Please read this before answering the following question.
Question 41 in this form is about dependent children.
Refer to Which questions should you complete? on page 3 of
this form and the letter sent with this form.
38 Please read this before answering the following questions.
All boxes in questions 38 and 39 MUST be completed.
The Base Tax Year for an Assistance for Isolated Children
payment is the financial year ending before 1 January of the
year of study.
If you have had a large increase or decrease in income, refer
to Parental income in the booklet Information you need to
know about your claim for Assistance for Isolated Children
(AIC).
If you (and/or you partner) did not receive income from
any of the following sources, please write ‘Nil’ in the
appropriate boxes.
Have you been asked to provide dependent children details?
$
$
B All income from outside Australia received in that country’s
last financial year
You
Type of currency
Yes
Go to next question
the customer named in question 8 of this claim) for whom these
payments are being, or will be, claimed:
• Assistance for Isolated Children (AIC) (Additional Boarding
Allowance)
• Youth Allowance (YA)
• ABSTUDY (living or boarding related allowances)
• Family Tax Benefit (FTB) (for child aged 16 years or over
in full-time secondary study who are attracting Family Tax
Benefit or may attract Family Tax Benefit in the future as
part of a lump sum claim)?
A Australian taxable income even if below the threshold
Your partner
Go to 42
41 Are there any other dependent children in your family (apart from
Give your (and your partner’s) income for the Base Tax Year.
You
No
Your partner
No
Go to next question
Yes
Give details below
Type of currency
1 Family name
C Net investment losses
(include losses on investments/shares and rental properties,
i.e. negative gearing)
Your partner
You
First given name
$
Date of birth
$
D Reportable superannuation contributions paid by you (or your
/
/
partner) or on your (or your partner’s) behalf (e.g. voluntary
salary sacrificed amounts).
You
Your partner
Receiving (or recently claimed)
AIC
YA
ABSTUDY
$
2 Family name
$
FTB
E All child support and partner maintenance payments you
(and your partner) received, do not include Family Tax Benefit
Your partner
You
$
First given name
$
Date of birth
F All child support and partner maintenance payments you
(and your partner) paid out
You
Your partner
$
$
/
Receiving (or recently claimed)
AIC
YA
ABSTUDY
You must attach proof of your (and your partner’s)
income.
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/
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FTB
41 Continued
3 Family name
42 Please read this before answering the following question.
Questions 43 to 49 in this form are about payment details.
Refer to Which questions should you complete? on page 3 of
this form and the letter sent with this form.
First given name
Have you been asked to provide payment details?
Date of birth
/
No
Go to 50
Yes
Go to next question
/
Receiving (or recently claimed)
AIC
YA
ABSTUDY
43 Who are payments to go to:
Payments will be made to the applicant OR to an agent
authorised by the applicant.
FTB
4 Family name
The applicant
Go to 49
The boarding institution
Go to 50
The school
Go to 50
The organisation
Go to 47
First given name
Another agent
Date of birth
/
/
Receiving (or recently claimed)
AIC
YA
ABSTUDY
44 Agent’s name
Mr
FTB
Mrs
Miss
Other
Ms
Family name
5 Family name
First given name
First given name
Second given name
Date of birth
/
Go to next question
/
Receiving (or recently claimed)
AIC
YA
ABSTUDY
FTB
45 Agent’s address
6 Family name
Postcode
First given name
46 Agent’s contact details
Date of birth
/
Daytime phone number (
Receiving (or recently claimed)
AIC
YA
ABSTUDY
Mobile phone number
FTB
After hours phone number (
If you have more than 6 dependent children, attach a separate
sheet with details.
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)
/
Go to 49
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)
47 Where does the organisation want the AIC payment made?
51 Please read this before answering the questions about tax.
The bank, building society or credit union account must be in the
organisation’s name.
You are not breaking the law if you do not give us your (and
your partner’s) tax file number(s), but if you (and your partner)
do not provide them to us, or authorise us to get them from
the Australian Taxation Office, you may not be paid.
In giving us your (and your partner’s) tax file number in relation
to this claim you authorise us to use your (and your partner’s)
tax file number for other payments including social security
payments and services in future where necessary.
Name of bank, building
society or credit union
Branch where
organisation’s
account is held
Branch number (BSB)
Have you (and your partner) given us your tax file number(s)
before?
Account number
Account name
No
Go to next question
Not sure
Go to next question
Go to 53
Yes
52 Do you (and your partner) have a tax file number(s)?
48 Organisation’s tax file number?
If you have a partner, their TFN is only required to be provided
if Additional Boarding Allowance is being claimed.
Go to 54
You
49 Please read this before answering the following question.
No
Please call us on 132 318.
It is your responsibility to give the correct account details.
Please check that the Branch and Account numbers are
correct. Incorrect numbers will delay payments.
If you are directing your AIC payments to a school or boarding
institution, you do not need to provide their account details as
we will obtain this information direct from the school or
boarding institution.
Yes
Your tax file number
Your partner
No
Please call us on 132 318.
Yes
Your partner's tax file number
Where do you want your payment made?
The bank, building society or credit union account can be in your
name or your Agent’s name. A joint account is acceptable.
Name of bank, building
society or credit union
53 Which of the following forms, documents and other attachments
are you providing with this form?
If you are not sure, check the question to see if you should attach
documents.
Branch where your
account is held
Where you are asked to supply documents, please attach
original documents.
Branch number (BSB)
Account number
(this may not be your
card number)
Documents to verify details of your income
(if you answered 38)
Account held in the name(s) of
Documents to verify details of your income
(if you answered 39)
50 Please read this before answering the following question.
Question 51 and 52 in this form is about tax file numbers.
Refer to Which questions should you complete? on page 3 of
this form and the letter sent with this form.
Have you been asked to provide tax file number details?
No
Go to 53
Yes
Go to next question
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54
56 Statement on behalf of the organisation
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
humanservices.gov.au/privacy or by requesting a copy from
the department.
I declare that:
• the information provided in this form is complete and correct.
I understand that:
• giving false or misleading information is a serious offence.
• the Australian Government Department of Human Services
can make relevant enquiries to ensure the organisation
receives the correct entitlement.
Signature
www.
55 Statement
I declare that:
• the information I have provided in this form is complete and
correct.
• I have read and understand the list of events provided on
pages 17–18 of the booklet Information you need to know
about your claim for Assistance for Isolated Children
(AIC).
I understand that:
• 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 the correct
entitlement.
• personal information is protected by law and can be given to
someone else only in very special circumstances, where
Commonwealth legislation provides or where I give permission.
• the Australian Government Department of Human Services
may use any information contained in this claim to determine
eligibility for other payments.
• I must notify the Australian Government Department of Human
Services of any change(s) to this information, within 14 days
of the occurrence of any event listed on pages 17–18 of the
booklet Information you need to know about your claim
for Assistance for Isolated Children (AIC).
Your signature
Date
/
/
Your partner’s signature
Date
/
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/
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Date
/
/
AIC payments cannot start until this statement is signed and
the form is returned to us.