APPLICATION FOR A VARIATION OF CONDITIONS
OF ALLOCATION – RESIDENTIAL RESPITE
Section 17-2 of the Aged Care Act 1997
Important information for applicants
This application form should be used by approved providers to apply for a variation of the
conditions of allocation for places that have taken effect, where the only condition to be varied
relates to the number of respite days. If you wish to apply for a variation of other conditions
associated with residential care, or to vary the conditions for home care or flexible care places,
please use the form, ‘Application for a variation of conditions of allocation – residential, home care
and flexible care places’.
Under section 17-2 of the Aged Care Act 1997 (the Act), an approved provider to whom a place
has been allocated may apply in writing to the Secretary to vary the specific conditions to which the
allocation is subject under section 14-5.
Apart from these specific conditions, all allocations of places to an approved provider are subject to
general conditions under section 14-6 of the Act. These general conditions apply to all types of
places including community care places. A provider cannot apply to have these general conditions
varied.
The questions in this form reflect the provisions of Division 17 of the Act and Part 8 of the
Allocation Principles 2014 (the Principles).
The application must be made no later than 60 days before the proposed variation day. If
you need to lodge this application in less than the 60 day period, you should discuss this with the
Department and complete Attachment 1. If approved, the proposed day of variation specified in
the application to the Department becomes the variation day. The approved changes cannot be
recognised by the Department to have taken effect before the variation day. Providers who
subsequently find that they require a different variation day to the one specified on the application
will need to contact the Department and advise the Secretary in writing of the proposed change.
If the places proposed to be varied are allocated to more than one service, a separate application
form must be submitted in respect of each service.
If further information is needed to determine the application, the Secretary may give notice to the
applicant under section 17-3 of the Act, requesting that the further information required be provided
within 28 days.
If you are unclear about any of the questions in this application, you should contact 1300 653
227 and ask to speak with a Departmental Officer in your relevant state or territory in
relation to variations to conditions of allocation for residential respite care
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This is an approved form for the purposes of the Aged Care Act 1997
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Section A – Approved provider details
A1 Name of approved provider
A2 Postal address of approved provider
PO Box/Street & no.
Suburb/Town
State/Territory
Postcode
A3 Name of the residential aged care service to which the allocation relates
A4
Physical address of the residential aged care service
Street no. & name
Suburb/Town
State/Territory
Postcode
E-mail address
A5
Contact name (key personnel)
Title
Given name(s)
Family name
Position
Phone
Fax
E-mail address
A6 Residential aged care service ID
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Application for a variation of conditions of allocation – residential respite
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Section B– Details of requested variation
B1
When were the places you are proposing to vary allocated to your service?
dd /
mm
/ yyyy
B2
The conditions relating to respite care to which the allocation is subject under section
14-5 of the Act are specified in the Schedule of conditions of allocations attached to
the Notice of Allocation. Please list the condition(s) that you wish to vary, details of the
proposed variation(s) and the number of places that the proposed variation is to apply
to.
B3
What are the reasons for the proposed variation?
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Application for a variation of conditions of allocation – residential respite
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B4
What is the date of the proposed variation day?
dd /
B5
mm
/
yyyy
If this application is being made less than 60 days before the proposed variation
day, please use Attachment 1 of this form to request that the Secretary
determine another period.
Are any places that are proposed to vary included in a residential care service that is
an adjusted subsidy residential care service?
Yes
No

How many?
High:
Low:
B6
Are any places that are proposed to vary included in a residential care service, or
distinct part of the service, that has Extra Service status?
Yes
No
 Go to question B8

How many?
High:
Low:
B7
If any of the places proposed for variation relate to a ‘distinct part’ of a service with
approval for extra service status, explain how the ‘distinct part’ requirement for extra
service will continue to be met at the service once the places have varied. Attach a
plan if required.
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B8
Please provide details of the effect that the proposed variation will have on care
recipients.
B9
If the places have been allocated to meet the needs of a particular group (e.g. a
special needs group, people with dementia, couples), please provide details of how the
needs of the particular group(s) will continue to be met after the variation.
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Application for a variation of conditions of allocation – residential respite
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B10 Does the proposed variation of the conditions of the allocation involve the relocation of
places?
Note: Under section 14-5 of the Act, every place must be allocated in respect of a
specified location and a specified aged care service and any care provided in respect
of the place must be provided from the specified location and aged care service. A
place will effectively be relocated if the specified location and/or the aged care service
in respect of which the place was allocated is varied.
Yes
No
 Go to question B15
B11 Please provide the name and address of the proposed residential aged care service to
which the allocated places will be relocated.
Note: A variation of conditions cannot be approved where this would result in the
places moving to a different state or territory.
B12 Residential aged care service ID (if applicable – a new service may not yet have a
number).
B13 Does the proposed residential aged care service, or a distinct part of that service, to
which the allocated places will be relocated have Extra Service status?
Yes
No
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Application for a variation of conditions of allocation – residential respite
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B14 Do you wish some or all of the places that are transferred to be granted Extra Service
status?
Yes
No

If yes, you will need to complete Attachment 2
B15 How do you propose to ensure that the residential aged care service to which the
allocation being varied relates is financially viable after the variation?
B16 Will the proposed variation affect any conditions imposed as part of an agreement or
approval under the Aged Care Act 1997 or previous legislation (National Health Act
1953 or Aged or Disabled Persons Care Act 1954), for example, capital grant
agreement or extra service conditions of approval?
Yes
No

You will need to seek the Department’s agreement to a variation to the agreement or
the approval conditions. Please attach a separate letter seeking this variation.
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This is an approved form for the purposes of the Aged Care Act 1997
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Section C - Endorsement of application
This application can be signed only by those persons who are legally authorised to
sign for and on behalf of the approved provider and who are key personnel of the
provider. According to the Criminal Code Act 1995, giving false or misleading
information is a serious offence.
I/We have read the Aged Care Act 1997 and the Aged Care Principles.
I/We declare that the key personnel in my/our service are, and will continue to be, suitable to
provide aged care and are not disqualified individuals.
I/We consent to the Secretary of the Department of Social Services obtaining information
and documents from other persons or organisations, including the Australian Aged Care
Quality Agency and state, territory and Australian Government Departments/ authorities, to
assist in assessing the application.
Title
Given name(s)
Family name
Name
Position
Signature
Date
dd /
Title
Given name(s)
mm
/ yyyy
mm
/ yyyy
Family name
Name
Position
Signature
Date
dd /
Please forward this completed application form to:
Aged Care Branch
Department of Social Services
GPO Box 9820
In the capital city of the state or territory in which the aged care service is located.
(For ACT services, please send this form to NSW for assessment)
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Attachment 1– Request to determine a different application period
under section 17-2(5) of the Act
Under section 17-2(4) of the Act, the application for approval to vary an allocation of places
must be made no later than 60 days before the proposed variation day, or such period as the
Secretary determines under subsection 17-2(5) of the Act.
In this section the applicant may formally request that the Secretary determine another
period. The Secretary must be satisfied that the request is justified in the circumstances.
Please note that under section 17-5 of the Act, the Secretary must make a decision on the
application at least 14 days before the variation day.
1.
Will this application be received less than the 60 day application period?
YES
NO

You may request that the Secretary determine another period by providing an explanation in
the box below.
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Application for a variation of conditions of allocation – residential respite
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Attachment 2 – Proposal for Extra Service status
1.
How many places proposed for variation do you wish to be granted extra service
status?
2.
If the extra service approval at the new service is not for the ‘whole service’ or if you
are proposing to vary some places that would not become extra service places, please
explain how the extra service requirements in respect of a ‘distinct part’ will be met
when the places are varied. Attach a plan showing the extra service and
non-extra service parts.
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3.
Explain the extra service conditions that would apply to these places, including the
proposed standard of accommodation, food and services. You may make reference to
your existing conditions of extra service approval.
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4.
State the reasons why you believe that the proposal for the varied places to be granted
extra service status would not unreasonably reduce access to residential care by people
living in the region who are low-means care recipients, supported residents, concessional
residents and assisted residents.
5.
Explain any other benefits of the variation of the places that are proposed to be
granted extra service status, including benefits in terms of increased diversity of choice
or better access to continuity of care.
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This is an approved form for the purposes of the Aged Care Act 1997
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