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Ex-gratia assistance for New Zealand
non-protected special category visa holders –
South Australia Bushfires
January 2015
Purpose of this form
The ex-gratia payment will provide financial assistance to New Zealand citizens living in
Australia who hold a non-protected special category visa (subclass 444) and who are
adversely affected by the South Australia Bushfires in January 2015. The Australian Government
Disaster Recovery Payment (AGDRP) has been made available from 6 January 2015.
Who is eligible for
assistance
You, your partner and/or children may be eligible to receive the ex-gratia payment if you:
• are a New Zealand non-protected special category visa holder (subclass 444) in a disaster
declared local government area (LGA) where the AGDRP has been activated
• are 16 years of age or older
• have not already received an ex-gratia payment or an AGDRP for the disaster (not including
the Ex-gratia Income Support Allowance or the Disaster Recovery Allowance)
• have experienced one or more of the following:
– you have been seriously injured as a direct result of the disaster
– you are the immediate family member of a person who died as a direct result of the
disaster
– your home has been destroyed or has sustained major damage
– you are the principal carer of a dependent child who has experienced any of the
above,
and
• have participated in the Australian tax system for at least one year in the past 3 financial
years, 2011–2012, 2012–2013, 2013–2014 or are currently engaged in income generating
activities with a likelihood of paying tax in Australia on or before 6 January 2016.
Evidence of damage to your home may be required before we can approve your claim.
You may also be eligible to receive the ex-gratia assistance for any adult currently living
with you, who is financially dependent on you and who does not pay taxes in Australia,
if they were also affected by the disaster.
Who is a non-protected People who arrive in Australia on New Zealand passports are generally issued special
category visas on arrival. Generally, you will be a non-protected special category visa holder
special category visa
if you arrived in Australia after 26 February 2001.
holder
We will assess whether you are a protected or non-protected visa holder based on the
information you provide.
How much will be paid The ex-gratia assistance for New Zealand non-protected special category visa holders is a
one-off payment for people who have been adversely affected by the disaster.
If you are eligible you will receive:
• $1,000 per adult
• $400 for each child (under 16 years of age).
Please lodge your claim as soon as possible.
EM086.150109
Notes—1 of 3
Ex-gratia assistance for New Zealand non-protected special category visa holders
How long do I have to
claim
You have until 6 July 2015 to complete and lodge your claim for this payment.
How will payments be
made
Payments will be made to an Australian bank, building society or credit union account held
in your name. A joint account is acceptable. If you do not have an account please talk to us
about alternative arrangements.
Who can use this form
If you have a partner and your partner is also claiming, they can use this form or complete
a separate form.
What else you will
need to provide
Before you can get paid, you (and your partner) may need to show us:
• proof of identity (e.g. driver licence or passport)
• that you hold a New Zealand non-protected special category visa
• that you have participated in the Australian tax system for at least one year in the past
3 financial years, 2011–2012, 2012–2013, 2013–2014 or are currently engaged in income
generating activities with a likelihood of paying tax in Australia on or before 6 January
2016 by providing evidence such as a letter of employment from your employer, and
• evidence that you are eligible for this payment (e.g. hospital admission, evidence of
damage to principal home).
If you have any difficulty in obtaining or providing these documents, you should contact us
as soon as possible by calling 180 22 66.
If you are unable to provide this documentation because you have lost your tax records in
the fire you can obtain a copy of your notice of assessment from the Australian Taxation
Office.
Note: If you cannot demonstrate that you have paid tax, or are likely to, you should still lodge
a claim and we will contact you to discuss your circumstances further.
Filling in this form
•
•
•
•
Returning your form
Check that you have answered all the questions you need to answer and that you have
signed and dated this form. Please return this form to one of the following:
• by Post – Department of Human Services
Emergency Processing
Reply Paid 7815
CANBERRA BC ACT 2610
• by Fax – 1300 727 760
• or in person to your nearest Centrelink or Medicare Service Centre.
Please use black or blue pen.
Print in BLOCK LETTERS.
with a or .
Mark boxes like this
Go to 5 skip to the question number shown. You do
Where you see a box like this
not need to answer the questions in between.
Please lodge your claim as soon as possible.
EM086.150109
Notes—2 of 3
Ex-gratia assistance for New Zealand non-protected special category visa holders
For more information
Go to our website humanservices.gov.au/disaster or call us on 180 22 66 or visit one of
our Service Centres.
www.
To speak to us in languages other than English, call 131 202.
If you are outside Australia at the time of the disaster, you may contact us by phone.
To view international numbers go to our website humanservices.gov.au/contact
www.
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.
Terms and Conditions
for SMS
We may send you information messages appropriate to your circumstances. No Australian
Government Department of Human Services generated SMS or email will contain your name
or contact details.
You will not be required to respond by SMS or email to any Department of Human Services
generated messages. These services are voluntary and you are able to withdraw at any
time. We will not include direct links to any website within an email from this service.
The Social Security (Administration) Act 1999 and the Electronic Transactions Act 1999
together enable the Department of Human Services to send SMS notifications to customers
covering the types of decisions set out in this claim.
Please lodge your claim as soon as possible.
EM086.150109
Notes—3 of 3
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Ex-gratia assistance for New Zealand
non-protected special category visa holders –
South Australia Bushfires
January 2015
1
7
Are you a New Zealand citizen who arrived in Australia on a New
Zealand passport?
You are not eligible for this assistance.
Only a New Zealand citizen is to complete this
claim form.
No
Postcode
Go to next question
Yes
8
2
Your permanent address in Australia
Your temporary address in Australia
Have you applied for, and been granted, an Australian Permanent
Resident’s Visa?
Go to next question
No
Postcode
Yes
You are not eligible for this assistance.
Call us on 180 22 66.
9
3
How can we contact you?
Have you paid tax in Australia in one or more of the past 3
financial years: 2011–2012, 2012–2013, 2013–2014?
Phone number (
)
To help us serve you better, please provide your mobile number.
4
No
Go to next question
Yes
Go to 5
Mobile phone number
Note: This mobile number will automatically be subscribed to
our electronic messaging service. We may use this mobile
number to contact you. For Terms and Conditions, go to our
website humanservices.gov.au/em
Are you currently employed or are you earning an income in
Australia, and there is a likelihood that you will pay tax in
Australia on or before 6 January 2016?
No
You may not be eligible for this assistance.
Call us on 180 22 66.
Yes
You will need to attach your payslips or a letter
of employment from your employer.
Go to next question
www.
10 Do you have a Centrelink Reference Number?
No
Go to next question
Yes
Your Centrelink Reference Number (if known)
Go to 15
5
Your name
Mr
Mrs
Miss
Ms
11 What is your country of birth?
Other
Family name
12 What type of visa did you arrive on?
First given name
New Zealand passport
(special category visa)
Second given name
6
/
Permanent
Go to next question
Temporary
Go to next question
Unknown (e.g. arrived
on parent’s passport)
Your date of birth
Go to 14
Go to 14
/
CLK0EM086 150109
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13 Your visa details on arrival
20 Are you (and your partner) claiming for any dependent children?
Visa sub class
Date visa granted
/
/
Go to next question
Yes
Current visa details
Visa sub class
Give the children’s details (only one person can be paid
for each child)
Child’s family name
Child’s given names
Date visa granted
/
Go to next question
Child 1
14 Has your visa changed since you arrived in Australia?
No
No
Yes
/
Child’s date of birth
/
15 Do you have a partner who was living with you and was also
affected by the disaster?
/
Child’s sex
Male
Female
Child's permanent address (if different to question 7)
No
Go to 20
Yes
Who is claiming a payment on this form?
Postcode
Go to 20
You
Child 2
Go to next question
You and your partner
Child’s family name
16 Your partner’s name
Mr
Mrs
Miss
Ms
Child’s given names
Other
Family name
Child’s date of birth
/
First given name
/
Child’s sex
Male
Female
Child's permanent address (if different to question 7)
Second given name
Postcode
If you are claiming for more than 2 dependent children, attach
a separate sheet with details.
17 Your partner’s date of birth
/
/
18 Your partner’s permanent address, in Australia
Postcode
19 Does your partner have a Centrelink Reference Number?
No
Go to next question
Yes
Your partner’s Centrelink Reference Number (if known)
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21 Are you claiming for a dependent adult who meets ALL of the
24 Indicate which financial year(s) you have lodged a tax return or
an activity statement with the Australian Taxation Office.
Tick all that apply
following criteria:
• who is 16 years of age or older
• who is currently living with you
• who is financially dependent on you
• who does not pay taxes in Australia, and
• who was affected by the disaster?
2011–2012
2012–2013
2013–2014
No
Go to next question
Yes
Give details below
We may need to contact you to collect more
information.
You will need to attach the original Notice of
Assessment or your tax return as evidence that you
have paid tax in Australia.
See What else you will need to provide, in the Notes,
if you do not have these documents with you.
Family name
Currently engaged in income generating activities with a
likelihood of paying tax in Australia on or before
6 January 2016
Given names
25 Please read this before answering the following question.
Date of birth
A disaster can impact on you physically and/or emotionally.
Our social workers may be able to provide support and/or a
referral to assist you.
Sex
/
/
Male
Female
Country of birth
Would you like one of our social workers to contact you?
No
Yes
Permanent address (if different to question 7)
26 Where do you want your payment made in Australia?
Postcode
The bank, building society or credit union account must be in
your name. A joint account is acceptable.
If you are claiming for more than 1 dependent adult, attach a
separate sheet with details.
Name of bank, building
society or credit union
Branch where your
account is held
22 Date you were affected by the disaster
/
Branch number (BSB)
Account number
(this may not be your
card number)
/
23 How were you (and/or your child(ren), your partner and/or a
Account held in the name(s) of
dependent adult) affected by the disaster?
Tick all that apply for each column
1 – you (and/or your child(ren))
2 – your partner
3 – a dependent adult
1
2
If your partner (if you have one) is claiming a payment and
they would like it made to a different bank account in
Australia, attach a separate sheet with details.
3
You are an immediate family member of
a person who died
as a direct result of this disaster
Seriously injured
Your residence has been destroyed
Your residence has suffered major damage
Attach any relevant evidence to support your claim.
EM086.150109
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27
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 disclosed
to other parties for the purposes of research, investigation or
where you have agreed or it is required or authorised by law.
Human Services may disclose limited personal information
about you to individuals when your circumstances affect their
entitlement to payments and services. Your information may
be disclosed to the Attorney-General’s Department, the
Department of Immigration and Border Protection and their
service providers, or as authorised or required by law. Relevant
information may be disclosed to Australian and State
Government Departments and Agencies who are involved in
the joint administration of this disaster.
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.
www.
28 Statement
I declare that:
• I have read the privacy notice outlined above.
• 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 make sure I receive the correct
entitlement.
• I must tell the Australian Government Department of Human
Services of any changes to this information within 14 days.
• any overpayment will be recovered.
Your signature
Date
/
/
Office Use only
CSA Logon ID
Your partner's signature –
if they are also claiming a payment
Location claim taken
Date
/
Priority payment
/
No
Yes
No
Yes
Payment delivery method
Cheque number
See the Notes on how to return your form.
POI provided (e.g. driver
licence, Medicare card)
Eligibility evidence attached
Notes
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