Australian Government Disaster Recovery Payment
Tropical Cyclone Debbie
March 2017
1
6
Please read this before answering the following questions.
The Australian Government Disaster Recovery Payment is for
people significantly affected by a disaster and not for minor
damage or inconvenience (e.g. temporary loss of access to a
property or food spoilage).
The Australian Government Department of Human Services
will do regular audits and you may be asked to provide
evidence to support your claim.
Mr
7
Go to next question
Other
Have you ever used or been known by any other name
(e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)?
No
Go to next question
Yes
Give details below
Other name
Type of name (e.g. name at birth)
If you have more than 1 other name, attach a separate sheet
with details.
This includes an interpreter for people who have a hearing or
speech impairment.
To speak to us in languages other than English, call 131 202.
Yes
Ms
Second given name
Do you need an interpreter when dealing with us?
Go to 5
Miss
First given name
Returning this form
Please return this form to one of the following:
• post your claim form to:
Reply Paid 7815
CANBERRA BC, ACT 2610
or • take your claim to your nearest Department of
Human Services service centre or any Agent.
or • fax your claim form to: 1300 727 760.
Please make sure any accompanying documentation
is also clearly identified with your name.
No
Mrs
Family name
For more information
If you are not sure about your claim, or you need more
information, including details about the date you need to lodge
your claim by, if you will be required to provide documentation
to confirm your identity, or other assistance you may be
entitled to, please refer to humanservices.gov.au/disaster
or call us on 180 22 66.
Note: Call charges may apply.
2
Your name
8
Your gender
Male
Female
9
Your date of birth
//
3
What is your preferred spoken language?
10 Your principal place of residence
4
What is your preferred written language?
Postcode
5
11 What date did you start living at this address?
Do you have a Centrelink Reference Number?
No
Go to next question
Yes
Your Centrelink Reference Number (if known)
//
CLK0EM161 170403
EM161.170403
1 of 6
12 Was this your principal place of residence during the disaster?
No
Go to next question
Yes
Go to 15
18 Please read this before answering the following questions.
To receive an Australian Government Disaster Recovery
Payment, you must be an Australian resident living
permanently in Australia.
‘Permanently’ means you normally live in Australia on a
long-term basis. Holidays or short trips outside Australia
would not affect this.
For more information on residency, go to
humanservices.gov.au/residencedescriptions
13 What was your principal place of residence during the disaster?
Postcode
Are you living in Australia permanently?
14 When did you live at this address?
From
No
To
//
Yes
//
19 What is your country of birth?
15 Do you have a temporary or postal address?
A postal address can be a PO Box.
No
Go to next question
Yes
Give details below
20 Are you an Australian citizen or resident?
No
Go to next question
Yes – Resident
Go to next question
Yes – Citizen
Date you became an Australian citizen
//
Go to 23
Postcode
21 What is your current type of visa?
This address is:
Tick ONE box only
Temporary address
Go to next question
Postal address
New Zealand passport
(Special Category visa)
Permanent
Go to 17
Temporary
Unknown (e.g. arrived
on parent’s passport)
16 What date did you start living at the address given at 15?
//
Go to 23
Go to next question
Go to next question
Go to 23
22 What are your current visa details?
17 How can we contact you?
Visa sub class
//
Phone number ()
To help us serve you better, please provide your mobile number
23 Do you have a partner?
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
EM161.170403
Date visa granted
No
Go to 30
Yes
Go to next question
24 Does your partner have a Centrelink Reference Number?
2 of 6
No
Go to next question
Yes
Your partner’s Centrelink Reference Number (if known)
25 Your partner’s name
Mr
Mrs
Miss
30 Are you claiming for any dependent children under 16 years
Ms
of age?
Other
Family name
No
Go to next question
Yes
Give the children’s details (only one person can be
paid for each child)
Child 1
First given name
Child’s family name
Second given name
Child’s given names
26 Has your partner ever used or been known by any other name
Other name this child has been known by
(e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)?
No
Go to next question
Yes
Give details below
Child’s date of birth
//
Child’s gender
Male
Female
Child’s principal place of residence (if different to question 10)
Other name
Postcode
Were you the principal carer
of this child at the time of the
disaster?
Type of name (e.g. name at birth)
If your partner has more than 1 other name, attach a separate
sheet with details.
No
Yes
Child 2
Child’s family name
27 Your partner’s gender
Child’s given names
Male
Female
Other name this child has been known by
28 Your partner’s date of birth
//
Child’s date of birth
//
29 Was your partner adversely affected by the disaster?
No
Yes
EM161.170403
Child’s gender
Male
Female
Child’s principal place of residence (if different to question 10)
Go to next question
Your partner will need to claim separately for this
assistance.
Go to next question
Postcode
Were you the principal carer
of this child at the time of the
disaster?
3 of 6
No
Yes
30 Continued
Child 3
33 How were you (and/or your dependent child(ren)) directly
affected by the disaster?
Child’s family name
Tick ALL that apply
My immediate family member has died or is missing
25% of the interior of my residence is disaster affected
Child’s given names
25% of my residence is exposed to the elements
My residence has been destroyed or must be demolished
Other name this child has been known by
The interior of my residence has been affected by sewerage
My residence has been declared structurally unsound
Child’s date of birth
//
Child’s gender
Male
I was seriously injured
Female
I am the principal carer of a dependent child:
Child’s principal place of residence (if different to question 10)
whose immediate family member has died or is missing
whose residence has had the interior disaster
affected, by 25%
Postcode
Were you the principal carer
of this child at the time of the
disaster?
No
whose residence has been exposed to the elements, by 25%
whose residence has been destroyed or must be
demolished
Yes
whose residence has had the interior affected by sewerage
If you are claiming for more than 3 dependent children, attach
a separate sheet with details.
whose residence has been declared structurally unsound
who was seriously injured
Please explain:
• how your (or your dependent child(ren)s) residence suffered
major damage, including details of how many rooms are in
the residence and how many were affected, and/or
• how the residence was destroyed, and/or
• details of any injuries, including details of any hospital
admission or other treatment
• any other details which will assist us in determining how
you were adversely affected by this disaster.
31 Do you wish to receive your payment in instalments?
You can receive your payment in 2 instalments, paid over
2 fortnights.
No
Yes
32 Where do you want your payment made?
IMPORTANT: The following are not considered adversely
affected criteria for this payment:
• your home was without a particular utility service
(electricity, water, gas, sewage services or another
essential service), or
• you have been stranded in your home, or unable to gain
access to your home.
The bank, building society or credit union account must be in
your name. A joint account is acceptable.
Note: Payments cannot be made into an account used
exclusively for funding from the National Disability Insurance
Scheme.
Name of bank, building
society or credit union
Branch where the
account is held
Branch number (BSB)
Account number
(this may not be your
card number)
Account held in the name(s) of
Attach any relevant evidence to support your claim.
34 Date you were affected by the disaster
//
EM161.170403
4 of 6
38 Statement
35 Please read this before answering the following question.
I declare that:
• the information I have provided in this claim is complete and
correct
• I have read the privacy notice on this page.
I understand that:
• giving false or misleading information is a serious offence.
• this payment is for people significantly affected by a disaster
and not for minor damage or inconvenience.
• the Australian Government Department of Human Services
can make relevant enquiries to make sure I receive the
correct entitlement.
• the Australian Government Department of Human Services
may request evidence to support any claims made on this
form.
• any overpayment will be recovered.
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.
Would you like a Centrelink social worker to contact you?
No
Go to next question
Yes
What number would you like to be contacted on?
()
36 Checklist
Please tick what information has been provided with the
claim. If verification documentation is not provided with this
claim it will need to be provided within 28 days.
All questions on this claim have been completed
Signature
Proof of identity that add up to the value of 50 points
(you may need to show us one document showing Proof of
Birth or Proof of Arrival in Australia, or any other approved
documents that add up to the value of 50 points,
for example, driver’s licence (40 points), bank card/
statement (40 points), Medicare card (20 points))
Date
//
Any additional relevant evidence to support your claim
(if you answered Yes at question 33)
37
IMPORTANT INFORMATION
For how to return this form, see page 1.
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 where you have agreed to that, or where it
is required or authorised by law (including for the purpose of
research or conducting investigations).
Relevant information may be given to Australian and State
Government Departments and organisations who are
involved in the joint administration of this disaster.
You can get more information about the way in which the
department will manage your personal information, including
our privacy policy, at humanservices.gov.au/privacy
EM161.170403
5 of 6
Office Use only
SO Logon ID
Identity type
Serial number
Issue date
Expiry date
//
State of issue
//
Country of issue
Identity type
Serial number
Issue date
Expiry date
//
State of issue
//
Country of issue
Identity type
Serial number
Issue date
Expiry date
//
State of issue
//
Country of issue
Identity type
Serial number
Issue date
Expiry date
//
State of issue
//
Country of issue
Original document sighted and returned
EM161.170403
6 of 6