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Request for an Assets Assessment Form - Text Version

Below is the text from the Request for an Assets Assessment form for accessibility purposes. Please print the form and use this text to assist in completing the form.

PDF printable version of the Assets Assessment Form (PDF 585 KB)

Front Cover:

Australian Government - Department of Health and Ageing logo
Permanent Residential Aged Care
Request for an Assets Assessment

This form is used to provide the necessary information so that the net value of your assets can be assessed by Centrelink or the Department of Veterans’ Affairs (DVA).

Important:

It is not compulsory to have an assets assessment to enter residential aged care.
Please read page 3 of the accompanying Information Booklet to work out whether it would be to your advantage to have an assets assessment. For information about whether you need to have an assets assessment call 1800 200 422*.

This form is not an application for Financial Hardship Assistance. For information about Financial Hardship Assistance please call 1800 200 422*.

Returning the form

• Please return the completed form to Centrelink or DVA. Full instructions on where to send it are on the back page of this form.
• Please do not send this form to the Department of Health and Ageing.

Page 2

Important information about this form

Skip instructions

Depending on your answer to certain questions, you may be given a ‘Skip’ instruction. ‘Skip’ instructions allow you to skip past questions that are not relevant to you.
You must follow all Skip instructions that apply to you.
‘Skip’ instructions generally follow a Yes or No answer box and look like this:
Yes
No - Skip to A6.
If there is no ‘Skip’ instruction it means you need to continue to the next question.

Do you need to complete all sections of this form?

Depending on your circumstances, you may not need to complete all sections of this form.
Some sections start with an ‘introductory question’ which looks like the one below. You must answer each of these introductory questions whether you think the section applies to you or not.

Do you need to complete this section?

Example of an introductory question leading in to each Section throughout the form.
No - Skip to Section X — you do not need to complete this section
Yes - You do need to complete this section — please go to the next question

Further information

An information symbol and the accompanying text indicate that there is further information contained in the Information Booklet.

Attaching documents

Depending on your answers you may be required to provide additional documentation with your form. If you do need to attach documents you will be told what to attach.
You do not need to provide the original documents - a photocopy is adequate.
Top of page

Privacy

The legal authority for the use and disclosure of the information collected in this form is set out on page 8 of the Information Booklet.

Page 3

Section A Personal details

Are you sure you need to complete this form?
Please do not complete this form until you have read page 3 of the accompanying Information Booklet and are certain that you need an assets assessment. For more information call 1800 200 422*

A1 Your full name (the person the assessment is for)
Title (e.g. Mr, Mrs, Miss, Ms)
Surname or family name
Given names

A2 Sex
Female
Male

A3 Date of birth

A4 Home address
If you are already in residential aged care or are in a hospital awaiting entry to a residential aged care home, you should write down your previous home address.

A5 Address for correspondence (if different from above)
If you receive an income support payment (for example, Age Pension or Service Pension) from Centrelink or DVA, do you want Centrelink or DVA to use this address for income support correspondence?
‘Income support payments’ are defined on page 2 of the Information Booklet.
Not applicable
Yes
No

A6 Contact phone numbers
Daytime
Mobile

A7 Do you have a current Aged Care Assessment Team (ACAT) approval for entry into permanent residential aged care?
Yes
No

An image of a barcode for scanning purposes.

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A8 Are you currently receiving an income support payment from Centrelink or DVA?
‘Income support payments’ are defined on page 2 of the Information Booklet.
No
Yes - Which agency do you receive the payment from?
Centrelink
Type of payment received
Centrelink Customer Reference Number requested
DVA
Type of payment received
DVA file number requested

A9 Are you currently receiving care in a hospital?
No
Yes - Name of hospital

A10 Are you currently residing in permanent residential aged care?
No
Yes - Name of the home Phone number
Have you paid an accommodation bond?
No
Yes - What is the current balance?

Note: Please see page 3 of the Information Booklet to see if it is necessary for you to have an assets assessment.
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A11 Are you requesting this assets assessment for (tick one box only):
A future admission to an aged care home

Note: You need to complete this form based on your current circumstances.

A move to a different aged care home

Note: You need to complete this form based on your current circumstances.

Your current admission
Date of that admission
A previous admission
Date of that admission

Note: You need to complete this form based on your circumstances at the date of that admission.

A12 Do you have a partner?
‘Partner’ is defined on page 6 of the Information Booklet.
No - Skip to A18
Yes

A13 Your partner’s full name
Title (e.g. Mr, Mrs, Miss, Ms)
Surname or family name
Given names

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A14 Your partner’s sex
Male
Female

A15 Your partner’s date of birth

A16 Your partner’s residential address

A17 Is your partner currently receiving an income support payment from Centrelink or DVA?
‘Income support payments’ are defined on page 2 of the Information Booklet.
No
Yes - Which agency does your partner receive the payment from?
Centrelink
Type of payment received
Centrelink Customer Reference Number requested
DVA
Type of payment received
DVA file number requested

A18 Are you (and/or your partner) a veteran or dependant of a deceased veteran?
No
Yes - Did you (and/or your partner) receive a payment of $25,000 from the Australian Government as compensation for internment by:
North Korean forces during the Korean War?
No
Yes
Japanese or Axis forces during World War II?
No
Yes
If you (and/or your partner) received one of these payments, the compensation payment amount will be deducted from the value of your assets.

A19 Do you want to provide an estimate of the net market value (resale value) of your (and your partner’s, if applicable) household contents and personal effects?

Note: Even if Centrelink or DVA already has information on the value of your household contents and personal effects, it is important that you update this information to take account of any depreciation or increase in value.

No - The value of your household contents and personal effects will be taken to be $5,000.
Skip to Section B
Yes - What is the estimated net market value* of your (and your partner’s, if applicable) household contents and personal effects?
This estimate may be higher or lower than $5,000.

Note: The market value is not the replacement or insured value, it is the amount you would get if you sold the item(s).
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Page 6

Section B Contact person

Do you need to complete Section B?
Do you want to nominate someone (other than yourself) whom Centrelink or DVA can contact about this aged care assets assessment?
No - Skip to Section C — you do not need to complete this section.
Yes - You do need to complete this section — please go to question B1 below.

B1 Who do you want to nominate?
My partner
Your partner’s daytime phone number
Mobile
Skip to Section C — you have completed this section.

Someone else
Please give their details
Title (e.g. Mr, Mrs, Miss, Ms)
Surname or family name
Given names
Address for correspondence with contact person
Daytime phone number
Mobile
Their relationship to you (e.g. son, friend)

Note: If you would like to nominate more than one contact person, please provide a separate sheet with the other person’s details.

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Section C Your home

Do you need to complete Section C?
During the past 2 years have you (and/or your partner):

• owned or part-owned a home (including a mobile home); or
• owned or part-owned a unit in a retirement village; or
• lived in a retirement village unit under an agreement where an amount was paid for the right to live in the retirement village?

No - If you answered No to all of the 3 questions above, Skip to Section D — you do not need to complete this section.
Yes - If you answered Yes to any of the 3 questions above, you do need to complete this section — please go to question C1 below.

Page 5 of the Information Booklet tells you how your home is treated for the assets assessment.

C1 In the past 2 years, have you (and/or your partner) lived in a retirement village?
Please refer to page 5 of the Information Booklet for information about Retirement village homes.
No
Yes - Skip to C23

C2 Do you (and/or your partner) currently own (or part-own) a home?

Note: Also answer ‘Yes’ to this question if you (and/or your partner) are paying off a mortgage on your home or if your home is owned by a Private Trust or a Private Company that you (and/or your partner) control.

No - Skip to C6
Yes
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C3 Is your home a mobile home such as a caravan or a boat (or similar dwelling)?
No - Go to C4
Yes - What is the current market value of the home?
Please attach documentation indicating the current market value of the home.
Do you have a partner who lives in the mobile home?
No - Skip to C31
Yes - Skip to Section D — you have completed this section.

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C4 Do you have a partner who lives in your home?
No - Skip to C8
Yes - Go to C5

C5 Is the land on which your home stands more than 2 hectares (5 acres)?
No – Skip to Section D – you have completed this section.
Yes - Skip to C8

C6 Note: If you (and/or your partner) have owned or part-owned a home (including a mobile home) in the past 2 years, but you do not own it now, the value of your interest in that former home may be used to work out if you are eligible for government assistance.
Did you (and/or your partner) sell your home in the past 2 years?
No - Go to C7
Yes - Date the home was sold
Did you have a partner at the time the home was sold?
No
Yes
What was the total amount you (and your partner, if applicable) received?
What was the total amount you (and your partner, if applicable) incurred in finalising the sale of the home, for example, a mortgage, taxes?

Please attach documentation verifying the:

• sale price of the home, for example, a solicitor’s settlement letter or sale contract, and
• the amount of expenses incurred (if any) in finalising the sale of the home.

Skip to Section D – you have completed this section.

C7 Did you (and/or your partner) transfer the title of your home in the past 2 years?
No - Skip to Section D – you have completed this section.
Yes - Date the title was transferred
Did you have a partner at the time the title of the home was transferred?
No
Yes
What was the market value of your (and your partner’s, if applicable) interest in the home at the time of transfer?
Please attach documentation verifying the value of the home, for example, a solicitor’s settlement letter or transfer document.

Skip to Section D – you have completed this section.
Top of page

Page 9

Details for valuation of your home
C8 What is the address of your home?

C9 What type of property is your home?
House
Part of a farming property
Townhouse (including duplex/triplex)
Self-contained flat (part of or attached to a house)
Unit/flat - How many units/flats are in the block?
Other - Please specify

C10 What is the share of ownership (as indicated on the property title)?
Note: For the purposes of this question, disregard any financial interest held by a financial institution in the form of a mortgage.
Self
Partner
Others

C11 What is the legal description (lot/section number) of the land?

Note: This information can be found on a rates notice.

Lot
Section

C12 What is the area/dimensions of the land?

Note: You do not need to answer this question if your home is a unit or flat.

Square metres, or
Hectares, or
Acres

Page 10

C13 What are the details of your home?
Number of bedrooms
Number of bathrooms
Number of garages
Approximate age of the home in yearsFloor area in squares or square metresYour assessment of the condition of the home: Good, Fair, Poor
Type of construction:
Exterior (e.g. brick, timber, fibro)
Roof (e.g. iron, tiled)
Is there anything that may affect the value of the home (e.g. swimming pool, new kitchen, no off-street parking)?

C14 Is the land on which your home stands more than 2 hectares (5 acres)?
No - Go to C15
Yes - What is the estimate of the value of:

• the home and surrounding 2 hectares (5 acres)
• the remainder of the property

Skip to C16

C15 What is your estimate of the current market value of the property, including land and buildings?

Note: You do not need to have the property professionally valued. We may have an approved government valuer do this at no cost to you.
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C16 Is your home part of a farm property?
No - Skip to C31
Yes

Page 11

Farm information

This information is needed by the valuer to verify the value of the property in order to determine the value of the home on it.

C17 What is the farm property primarily used for (e.g. grazing, wheat, hobby)?

C18 Is the farm property currently operational / viable?
No
Yes

C19 Is it possible to subdivide the farm property or farm home?
No
Yes

C20 Are there any improvements on the farm property?
No
Yes - Please complete the table

C21 Is there any fencing on the property?
No
Yes – Type, Condition

C22 Please list any other constructions located on the property (e.g. workers’ quarters, manager’s house)
Skip to C31

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Retirement village home

C23 Do you currently live in a retirement village?
No - Skip to C27
Yes

C24 Do you have a partner living with you in the retirement village?
No
Yes - Skip to Section D — you have completed this section.

C25 What amount will be paid to you (and/or your partner) when the retirement village unit is vacated (from the sale of the unit, or a refund of an amount paid under the licensing agreement, or a refund of an entry contribution)?
Please attach supporting documentation showing the amount payable to you

C26 Do you have an outstanding loan which was incurred to purchase the unit or for the right to live in the retirement village?
No - Skip to Section D — you have completed this section.
Yes - What is the amount owing on the loan?
Please attach a copy of the most recent statement for the loan
Skip to Section D — you have completed this section.

C27 When did you leave the retirement village?

C28 Did you have a partner living with you in the retirement village?
No
Yes - Is your partner still living with you in the retirement village?
No
Yes - Skip to Section D — you have completed this section.

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C29 What amount has been, or will be, paid to you (and/or your partner) as a result of the retirement village unit being vacated?

Note: This could be an amount from the sale of the unit, a refund of an amount paid under the licensing agreement, or a refund of an entry contribution. If you had a partner at the time this amount became payable, your share of this amount will be 50% of the total.

Please attach supporting documentation showing the amount payable
When was it paid to you, or when is it due to be paid?
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C30 At the time you left the retirement village, did you have an outstanding loan which was incurred to purchase the unit or for the right to live in the retirement village?
No
Yes - What was the amount owing on the loan?
Please attach a copy of the most recent statement for the loan

Page 14

Occupants of your home

This information is needed to decide if your home can be exempted from the assets assessment.

C31 Do you have a dependent child who lives in your home?
‘Dependent child’ is defined on page 6 of the Information Booklet.
No
Yes - Please give details of your dependent child
Surname or family name
Given names
Date of birth

C32 Have you had someone who has cared for you who has lived in your home for the past 2 years and is currently eligible to receive an income support payment from Centrelink or the Department of Veterans’ Affairs (for example, Age Pension or Service Pension)?
Note: A Carer’s Allowance is not an income support payment.
No
Yes

C33 Has a close relation (either your mother, father, sister, brother, child or grandchild) lived in your home for the past 5 years who is currently eligible to receive an income support payment from Centrelink or the Department of Veterans’ Affairs (for example, Age Pension or Service Pension)?
Note: A Carer’s Allowance is not an income support payment.
No
Yes

C34 If you have answered Yes to either (or both) C32 or C33, it is necessary for Centrelink or DVA to verify your carer’s or close relation’s occupation of your home and their eligibility to receive an income support payment.
Consent by carer or close relation
I consent to Centrelink or the Department of Veterans’ Affairs using information collected from me for the purpose of determining my eligibility for an income support payment for the additional purpose of determining under the Aged Care Act 1997 the value of the applicant’s assets, which may affect the amount the applicant can be asked to pay an aged care home for accommodation.
Signature of carer or close relation
Date
Surname or family name
Given names
Date of birth
Centrelink or DVA reference number
Relationship to applicant
Daytime phone number
Mobile

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Section D Debts

Do you need to complete Section D?
Do you (and/or your partner) have any debts that you currently owe, for example mortgages, loans and credit cards?
Do not include any:

• future or anticipated debts, or
• debts to be deducted from the sale price of a retirement village unit, or an entry contribution refund, that you have already included in Section C.

No – Skip to Section E – you do not need to complete this section
Yes - You do need to complete this section — please go to question D1 below.

Note: Some debts are assessed differently for aged care purposes than they are for pension purposes. Under the assets assessment, debts, charges and encumbrances on assets that you (and/or your partner) hold will be deducted from the net value of your assets.
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D1 Do you (and/or your partner) have any mortgages?
No
Yes - Please give details below
Address of property secured by the mortgage
Amount owing
Please attach a copy of the most recent statement for each mortgage

D2 Do you (and/or your partner) have any motor vehicle/boat/caravan loans?
No
Yes - Please give details below
Amount owing
Details of the motor vehicle/boat/caravan secured by the loan
Please attach a copy of the most recent statement for each loan

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D3 Do you (and/or your partner) have any outstanding credit card debts or other personal loans?
No
Yes - Please give details
Creditor
Amount owing
Your share
Partner’s share
Please attach a copy of the most recent statement for each loan

D4 Do you (and/or your partner) have any other debts not already listed on this form, for example, household and medical bills owing?
No
Yes - Please give details
Creditor
Amount owing
Your share
Partner’s share
Please attach supporting documentation

Page 17

Section E Other assets (including investment properties)

Do you need to complete Section E?
Do you currently receive an income support payment from Centrelink or the Department of Veterans’ Affairs (for example, Age Pension or Service Pension)?
No - You must complete this section — please go to question E1 below.
Yes - Centrelink or DVA already have details about your (and your partner’s) assets.
If the information held by Centrelink or DVA is not up to date, it could result in an incorrect assessment.
Do you need to advise Centrelink or DVA of any changes?
No – Skip to Section F – you do not need to complete this section
Yes - You only need to answer those questions in Section E where you need to give new information to Centrelink or DVA.

Note: If you are regarded as blind for income support payment purposes and you have not been means tested by Centrelink or DVA, you must complete this section.

Note: If you are already in permanent care and this assessment is for your current admission, any details you provide in this section should reflect your circumstances on the day you entered care.

If you need more space for any of your information, please attach a separate sheet with the details.

E1 Do you (and/or your partner) have any deposits with financial institutions?
This includes bank accounts, building society/credit union accounts, term deposits or money held in development funds.

Note: If you receive a payment from Centrelink or DVA, please include details of the account your payment is paid into.

No
Yes - Please give details
Name of institution
Account or term deposit number
Account balance
Your share
Partner’s share
Please attach proof of all account balances (e.g. copies of ATM slips, statements, passbooks)
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Page 18

E2 Do you (and/or your partner) have any investment bonds or debentures?
No
Yes - Please give details
Type of investment
Name of company
Current amount invested
Your share
Partner’s share
Please attach a document which gives details for each investment

E3 Do you (and/or your partner) have money on loan to another person or organisation including family members, relatives and friends?
No
Yes - Please give details
Who is it on loan to?
Date loaned
Amount owing
% loaned by you
% loaned by partner
Please attach a document which gives details of the loan, if available

E4 On or after 10 May 2006, have you (and/or your partner) given away, sold for less than their market value, or surrendered a right to any cash, assets, property or income?
This includes forgiven loans and shares in private companies.
No
Yes - Please give details
What you gave away or sold for less than its market value (e.g. money, car, land, farm)
Date given away or sold
What it was worth
What you got for it
Gift made by:
You
Partner

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E5 Do you (and/or your partner) own any shares, options, rights or convertible notes?
No
Yes - Please give details
Name of company
Number of shares
Your share
Partner’s share
Please attach a copy of the latest statement for each share holding

E6 Do you (and/or your partner) have any managed investments?
This includes unit and account based trusts, listed trusts, master trusts, insurance and friendly society bonds.
No
Yes - Please give details
Name of product
Policy number
Number of units
Your share
Partner’s share
Please attach documents which show details for each investment (e.g. certificate with the number of units or account balance)

E7 Do you (and/or your partner) have any life insurance policies that can be cashed in?
No
Yes - Please give details
Name of insurance company
Policy number
Surrender value
Your share
Partner’s share
Please attach a copy of the policy document and the latest statement for each policy

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E8 Do you (and/or your partner) have any superannuation assets from which lump sums can be withdrawn?
No
Yes – Please give details
Name of institution/ fund manager
Name of fund
Account balance
Your share
Partner’s share
Please attach a copy of the latest statement for each fund

E9 Do you (and/or your partner) have any income stream products, purchased before 20 September 2007, from which lump sums can be withdrawn?
No
Yes - Please give details
Name of institution/ fund manager
Name of fund
Account balance
Your share
Partner’s share
Please attach a copy of the latest statement for each fund
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E10 Do you (and/or your partner) have any income stream products purchased on or after 20 September 2007?
No
Yes - Please give details
Name of institution/ fund manager
Name of fund
Account balance
Your share
Partner’s share
Please attach a copy of the latest statement for each fund

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E11 Do you (and/or your partner) own any motor vehicles, boats, caravans or trailers?
No
Yes - Please give details
Make
Model
Year
Market value*
Your share
Partner’s share

* The current market value of your vehicle is the amount you would get if you sold it. It is not the insured or replacement value. If you have an outstanding loan or debt against the vehicles, please make sure you have provided the loan/debt information in Section F.

E12 Do you (and/or your partner) have an interest in a business (this includes a farm)?
No
Yes - What is your estimate of the total value of the interest?
(For a farming business, the value of grazing animals, produce, crops, plant and machinery should be included.)
Please attach a recent balance sheet which states your (and/or your partner’s) current interest in the business.

E13 Do you (and/or your partner) have a current interest in a private company?
No
Yes - What is your estimate of the total value of the interest?
You will be asked to provide more details at a later date.
Note: You are considered to have an interest in a private company if any of the following apply.
You (and/or your partner):

• are a shareholder, director or other office holder of the company
• are owed money by the company
• are able to benefit from the company
• can expect the director of a company to act in accordance with your wishes
• can expect the governing director or major shareholder to act in accordance with your wishes.

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E14 Do you (and/or your partner) have a current interest in a private trust?
No
Yes - What is your estimate of the total value of the interest?
You will be asked to provide more details at a later date.

Note: You are considered to have an interest in a private trust if any of the following apply.

You (and/or your partner):

• are the appointor, guardian or principal of the trust
• are a trustee
• are a shareholder or director of the trustee company
• are a beneficiary or included among the categories of beneficiaries
• are a unit holder
• are owed money by the trust
• are able to benefit from the trust
• can expect the trustee or appointor of a trust to act in accordance with your wishes.

E15 Do you (and/or your partner) have any special collections such as stamps, art work or antiques?
No
Yes - What is your estimate of the total value of these collections?
Please attach copies of valuation certificates or insurance valuations (if available)

E16 Do you (and/or your partner) have any other assets (apart from real estate) not declared elsewhere on this form?
No
Yes - What is the nature of these assets/investments?
What is your estimate of the value of these assets/investments?
Please attach supporting documentation (if available)

E17 Do you (and/or your partner) have any real estate properties other than your home?
No - Skip to Section F — you have completed this section.
Yes - How many real estate properties do you (and/or your partner) own or have an investment in?

Please note - If you have more than one investment property, you will need to photocopy and complete pages 23 – 25 for each property.

Page 23

Investment property

Remember If you have more than one investment property, you will need to photocopy and complete pages 23 – 25 for each property.

E18 What is the address of the property?

E19 What type of property is your investment property?
Vacant land
House
Townhouse (including duplex/triplex)
Self-contained flat (part of or attached to a house)
Unit/flat - How many units/flats are in the block?
Farm
Hobby farm
Retail premises
Commercial premises
Industrial premises
Other - Please specify

E20 What is the share of ownership (as indicated on the property title)?
Note: For the purposes of this question, disregard any financial interest held by a financial institution in the form of a mortgage.
Self
Partner
Others

E21 What is the legal description (lot/section number) of the land?

Note: This information can be found on a rates notice.

Lot
Section

E22 What is the area/dimensions of the land?

Note: You do not need to answer this question if the property is a unit or flat.

Square metres, or
Hectares, or
Acres
Top of page

Page 24

E23 What is your estimate of the current market value of the property, including land and buildings?

Note: You do not need to have the property professionally valued. We may have an approved government valuer do this at no cost to you.

E24 What are the details of the main building?
There are no buildings on the property
Number of bedrooms
Number of bathrooms
Number of garages
Approximate age of the home in yearsFloor area
In squares or square metresYour assessment of the condition of the home: good, fair, poorType of construction:
Exterior (e.g. brick, timber, fibro)
Roof (e.g. iron, tiled)
Is there anything that may affect the value of the home(e.g. swimming pool, new kitchen, no off-street parking)?

E25 Is the property a farm/hobby farm?
No - Skip to E32
Yes

Investment property — Farm information

E26 What is the farm property primarily used for? (e.g. grazing, wheat, hobby)

E27 Is the farm property currently operational/viable?
No
Yes

E28 Is it possible to subdivide the farm property or farm home?
No
Yes

Page 25

E29 Are there any improvements on the farm property?
No
Yes - Please complete the table

E30 Is there any fencing on the property?
No
Yes – Type, Condition

E31 Please list any other constructions located on the property (e.g. workers’ quarters, manager’s house)

Rental from investment property
This information is needed by the valuer to verify the value of your investment property.

E32 Is rental income received from the property?
No - Skip to Section F — you have completed this section.
Yes

E33 How many weeks per year is the property rented for?

E34 What is the gross amount of rent received for the property per week, month, year?

E35 What is your estimate of the annual outgoings (e.g. rates, maintenance)?

E36 Does the tenant pay all or part of the annual outgoings? All
Part - How much per year?

Page 26

Section F Document checklist

You may have been asked to provide documents (copies only) to support your answers to some of the questions. Please complete this checklist to make sure you have attached all the relevant documents.

Section C – Your home

• C3 - Current market value of mobile home – documents indicating the current market value
• C6 - Sale of the home – supporting documentation such as a solicitor’s settlement letter or the sale contract, and (if applicable) documents verifying the amount of expenses incurred in finalising the sale
• C7 - Transfer of the home – supporting documentation such as a solicitor’s settlement letter or transfer document
• C25 - Amount payable on departure from retirement village – supporting documentation showing the amount
• C26 - Outstanding loan for retirement village unit or entry contribution – most recent statement
• C29 - Amount paid or payable on departure from retirement village – supporting documentation showing the amount
• C30 - Outstanding loan for retirement village unit or entry contribution – most recent statement

Section D – Debts

• D1 - Mortgages – most recent statements
• D2 - Motor vehicle/boat/caravan loans – most recent statements
• D3 - Credit card debts or other personal loans – most recent statements
• D4 - Other debts – supporting documentation

Section E – Other assets

• E1 - Deposits with financial institutions – proof of all account balances such as ATM slips, statements, passbooks
• E2 - Investment bonds or debentures – supporting financial statements
• E3 - Money on loan – supporting documentation
• E5 - Shares, options, rights, convertible notes – supporting financial statements
• E6 - Managed investments – supporting financial statement showing the current unit holdings and account balance
• E7 - Life insurance policies – most recent policy schedules
• E8 - Superannuation assets – most recent statements
• E9 - Income streams, purchased before 20 September 2007, from which lump sums can be withdrawn – most recent statements
• E10 - Income streams purchased on or after 20 September 2007 – most recent statements
• E11 - Motor vehicles, boats, caravans or trailers – supporting documents such as an insurance policy schedule
• E12 - Business – recent balance sheet
• E15 - Special collections – valuation certificates or insurance valuations
• E16 - Other assets – supporting documentation

Please sign the form on the next page
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Page 27

Section G Declaration and consents

G1 - I declare that the information in this form is complete and correct. I also understand that giving false or misleading information is a serious offence.
I consent to the Department of Health and Ageing providing Centrelink or the Department of Veterans’ Affairs (DVA) with information about entry dates, levels of care, and previous aged care assets assessments, in relation to my current and/or any previous entry to aged care, if required to complete my assets assessment.
I consent to Centrelink or DVA:

• using information which has been collected from me for the purpose of determining my eligibility for an income support payment, for the additional purpose of completing my aged care assets assessment under the Aged Care Act 1997 to determine the amount of subsidy payable to an aged care home for my accommodation and the maximum amount I could be asked to pay the home for my accommodation
• using information collected from me for the purpose of completing my aged care assets assessment for the additional purpose of updating information held by Centrelink or DVA in relation to my eligibility for an income support payment
• disclosing personal information about me to my nominated contact person (if any)
• disclosing information collected from me for the purpose of completing my aged care assets assessment to the Department of Health and Ageing and Medicare Australia (acting on behalf of the Department of Heath and Ageing) in order to calculate the amount of subsidy payable to my aged care home for my accommodation and the maximum amount of accommodation charge I could be asked to pay the home (if applicable)
• advising aged care homes, to which I have applied to become a resident, of the progress of my assets assessment, if they request this information from Centrelink or DVA. My consent does not include advising aged care homes about the outcome of my assessment.

Signature of applicant (or person authorised to sign)

Date

G2 If this form was signed on behalf of the applicant, please provide the authorised person’s details
Title (e.g. Mr, Mrs, Miss, Ms)
Surname or family name
Given names
Address
Daytime phone number
Mobile
Relationship to applicant
Please attach the authorisation (tick whichever is applicable):
A copy of the power of attorney*
A copy of the administration order or financial management order

* If you wish to be registered as a power of attorney for future contacts with DVA, please provide a certified copy of your Power of Attorney documentation.

Note: If you have any queries about how to answer the questions on this form, please contact Centrelink on 1800 227 475 or DVA on 133 254 (if calling DVA from regional Australia phone 1800 555 254).

Page 28

Where to post the completed form and supporting documentation
Centrelink
Post your form and supporting documentation to Centrelink for processing if:

• you receive an income support payment (such as an Age Pension or a Disability Support Pension) from Centrelink, or
• you do not receive an income support payment from either Centrelink or the Department of Veterans’ Affairs.

See page 2 of the Information Booklet for a full list of income support payments paid by Centrelink.

All States/Territories
Centrelink
Seniors Service
Reply Paid 7808
CANBERRA BC ACT 2610

Department of Veterans’ Affairs (DVA)
Post your form and supporting documentation to the DVA office in your State or Territory for processing if you receive an income support payment (such as a Service Pension or an Income Support Supplement) from DVA.
See page 2 of the Information Booklet for a full list of income support payments paid by DVA.

ACT/NSW
Department of Veterans’ Affairs
Aged Care Assets Assessments
GPO Box 9998
SYDNEY NSW 2001

QLD
Department of Veterans’ Affairs
Aged Care Assets Assessments
GPO Box 9998
BRISBANE QLD 4001

SA/NT
Department of Veterans’ Affairs
Aged Care Assets Assessments
GPO Box 9998
ADELAIDE SA 5001

TAS
Department of Veterans’ Affairs
Aged Care Assets Assessments
GPO Box 9998
HOBART TAS 7001

VIC
Department of Veterans’ Affairs
Aged Care Assets Assessments
GPO Box 9998
MELBOURNE VIC 3001

WA
Department of Veterans’ Affairs
Aged Care Assets Assessments
GPO Box 9998
PERTH WA 6001

Department of Health and Ageing website is www.health.gov.au
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