Instructions

Accommodation details

When to use this form Use this form to provide details about your accommodation circumstances, including how much
rent you pay and whether you are, or have been a home owner.

Online services You can upload this form, with any supporting documents, online.
For more information about how to access an online account or how to lodge documents online,
go to servicesaustralia.gov.au/centrelinkuploaddocs
www.

What else you will Important note: If you are making a claim, you must return this form and all other supporting
need to provide documents at the same time you lodge your claim form. If you do not return all documents, your
claim may not be accepted. The only exception will be if you are waiting for medical evidence or
other documents from a third party.

For more information If you need help to fill in this form or you need more information about the questions, call us on:
ABSTUDY 1800 132 317
Disability and Carers 132 717
Employment Services 132 850
Families 136 150
Older Australians 132 300
Youth and Students 132 490
We can translate documents you need for your claim or payments for free.
To speak to us in your language, call 131 202.
Call charges may apply.
If you have a hearing or speech impairment, you can contact the TTY service Freecall™
1800 810 586. A TTY phone is required to use this service.

Mod(AC).2011
1 of 10
Having a partner You have a partner if we consider you a member of a couple. We consider you a member of a
couple if you are either:
• married
• in a registered relationship, or
• in a de facto relationship.
A registered relationship is where your relationship is registered under a law of a state or
territory. A de facto relationship is where you and your partner are in a relationship similar to a
married couple but are not married or in a registered relationship.
We may still consider you a member of a couple if you are not physically living with your partner.
For example, your partner may fly-in fly-out or live away for work, like military or oil rig workers.
For more information, go to servicesaustralia.gov.au/moc
www.

Mod(AC).2011
2 of 10
 Instructions
Filling in this form 8 Your current address

You can complete this form on your computer, print and sign it.
If you have a printed form:
• Use black or blue pen.
• Print in BLOCK LETTERS. Postcode
• Where you see a box like this Go to 1 skip to the question
number shown.
9 Your postal address (if different to above)

1 Your Customer Reference Number (if known)

Postcode

2 Your name
10 When did you move?
Mr Mrs Miss Ms Other
Family name / /

First given name

11 Is this change of address temporary, for example, less than
12 months?
No Go to next question
Second given name Yes When will you return to your usual address?
/ /

3 Your date of birth 12 Do you have a new phone number?

/ / No Go to 14
Yes Go to next question

4 Do you have a partner?

No Go to 7 13 Your contact details
Yes If your partner has a different home or postal Home phone number ( )
address to you, they will need to complete a Is this a silent number? No Yes
separate Mod AC form.
You need to tell us if you and your partner are not Mobile phone number
able to live together because of illness.
Fax number ( )
5 Your partner’s name
Work phone number ( )
Mr Mrs Miss Ms Other
Family name Alternative phone number ( )
Email
First given name

Second given name

6 Your partner’s date of birth

/ /

7 Have you changed your address?

No Go to 14
Yes Go to next question
CLK0Mod(AC) 2011

Mod(AC).2011
3 of 10
14 Do you (and/or your partner) own a home that you do not live in? 18 What is the name of the person you care for?
No Go to 25
Yes Go to next question

15 What is the reason you do not live in the home? Provide evidence of why the person you care for
requires a substantial level of care.
Travelling away from your home Go to 19
We will accept that a substantial level of care is
Being cared for away from your home Go to 16 required, if there is medical evidence (or assessment
by an Aged Care Assessment Team) that the person
Caring for someone away from your home Go to 17 you are caring for:
• is ill
Living away from home to study Go to 19
• is over age pension age and frail
Other Give details below • has recently been discharged from hospital
• is receiving Disability Support Pension and
requires assistance
• you receive Carer Payment or Carer Allowance for
Go to 19
providing care.

16 What is the name of your care provider?

19 Have you left your home temporarily, such as for less than
12 months, and intend to return to it?
No Go to next question
Provide evidence of your need for a substantial level Yes When do you expect to return to your home?
of care.
/ /
We will accept that a substantial level of care is
required, if there is medical evidence (or assessment
by an Aged Care Assessment Team) that you:
20 Has your home been let?
• are ill
• are over age pension age and frail No Go to 24
• have recently been discharged from hospital Yes Provide tax returns (if you have them) and
• are receiving Disability Support Pension and a list of the expenses involved in letting the
require assistance property (for example, rates, agent’s fees,
• your care provider is receiving Carer Payment or taxes, repairs, insurance).
Carer Allowance.
Go to 19to go to 19
Click
21 How much rent do you receive for your home per week?
$
17 Did you move into a private residence to care for someone?
No Go to 19
Yes Go to next question 22 What date was your property let?
/ /

23 Is there a mortgage owing on your home?

No Go to 25
Yes What is the balance of the mortgage owing?
$
What is the interest payable on the mortgage?
% Go to 25

Mod(AC).2011
4 of 10
24 Has your home been: 26 Is your (and your partner’s) home situated on a block of land
Left vacant larger than 2 hectares (5 acres)?
Occupied rent free No Go to next question
Occupied by partner Yes You will need to complete and return a Real
Occupied by carer of other family estate details (Mod R) form.
member(s) (for example, dependent child) If you do not have this form, go to
www.

Other Give details servicesaustralia.gov.au/forms

below Go to 28

27 Is your home situated on more than one title?

No Go to next question
Yes You will need to complete and return a Real
25 Which type of accommodation best describes where you (and
your partner) live? estate details (Mod R) form.
If you do not have this form, go to
www.

In the principal home of a parent and servicesaustralia.gov.au/forms

paying board and/or lodgings Go to 52

In a place where you (and/or your partner) 28 Is any part of the home property used to produce income?
pay private rent – this includes site or
mooring fees. Go to 58 Do not include rent from boarders or lodgers.

No Go to 31
In a home you (and/or your partner) own or
you own jointly with another person – Yes You will need to complete and return a
this can include: Business details (Mod F) form and a
• paying it off (mortgage) Real estate details (Mod R) form.
• a caravan, mobile home or boat Go to 26 If you do not have these forms, go to www.

servicesaustralia.gov.au/forms
In a home owned by: Go to 31
• a company in which you are a shareholder
or director
• a trust in which you or a member of your 29 Is the home held by a private trust?
family are a potential beneficiary or are
No Go to next question
named in the trust deed Go to 29
Yes You will need to complete and return a
In public housing, for example, housing Private Trust (Mod PT) form.
owned by the Housing Authority. This does If you do not have this form, go to
not include paying rent to a community
www.

servicesaustralia.gov.au/forms
housing organisation. Go to 32
Go to 31
In a boarding house, guest house, hostel,
hotel, campus or similar Go to 54
30 Is the home owned by a private company?
In a hospital or home for people with No Go to next question
disabilities Go to 54 Yes You will need to complete and return a
In an aged care home or nursing home Go to 35 Private Company (Mod PC) form.
If you do not have this form, go to
www.

In a retirement village Go to 42 servicesaustralia.gov.au/forms

Go to next question
In accommodation which you (and/or your
partner) have the right to use for life Go to 46

In accommodation where you pay no rent Go to 62 31 Do you pay site, ground or mooring fees for your (and your
partner’s) home (this could be for a caravan, mobile home
Other, for example, this could be where you or boat)?
(and/or your partner) do not have a fixed No Go to 62
address Give details
below Yes Go to 58

Go to 58
Mod(AC).2011
5 of 10
32 Is your (or your partner’s) name on the rental contract or lease 39 Read this before answering the following question.
agreement? Payments for accommodation may include:
No Go to next question • Accommodation Bond
Yes Go to 62 • Accommodation Charge
• Refundable Accommodation Deposit (RAD)
• Daily Accommodation Payment (DAP)
33 Is the primary tenant paying the market rate of rent? • Daily Accommodation Contribution (DAC)
No Go to next question • Refundable Accommodation Contribution (RAC).
Not Sure Go to next question
Did you (and/or your partner) pay, or agree to pay, a daily
Yes Go to 52 payment or a lump sum (either by instalments or in full) for
your accommodation to the Aged Care Provider?
34 Do you (and your partner) live with the primary tenant(s) and your This payment may have been a donation, a loan or some
(and/or your partner’s) income has been taken into account by type of payment which may be repayable to you in whole or
the public housing authority when calculating the rent? in part, if you leave. This payment does not include gifts or
No Go to 62 loans above the amount you had to pay for the right to your
accommodation.
Yes Go to 52
No Go to 62
Aged care home or nursing home Yes Amount of payment

35 What is the name of the aged care home or nursing home? $

Provide a copy of the signed accommodation

agreement(s).

40 Did you (and/or your partner) make a gift and/or loan in addition
36 What date did you (and/or your partner) move in? for the right to your accommodation?
You Your partner
No Go to 62
/ / / /
Yes Go to next question

37 How long will you (and/or your partner) be staying? 41 What was the additional amount paid as a gift and/or loan?
Long term or indefinitely Amount of gift
You Your partner Go to 39 $
Short term or temporary respite care Amount of loan
You Your partner Go to next question $
Go to 62
38 What date do you (and/or your partner) expect to leave?
You Your partner
/ / / /
Go to 62

Mod(AC).2011
6 of 10
 Retirement village Life interest

42 What date did you (and/or your partner) move into the 46 Did you (and/or your partner) pay any money or transfer any
retirement village? assets in return for this right to accommodation for life?
You Your partner No Go to next question
/ / / / Yes Go to 48

43 Did you (and/or your partner) pay an entry contribution? 47 Which option describes how you (and/or your partner) obtained
a life interest in a home without any exchange of money or
Your entry contribution may have been a donation, a loan or transfer of assets?
some type of payment that may be repayable to you in whole Go to 62
Inherited the life interest
or in part, if you leave. An entry contribution does not include
gifts or loans above the amount you had to pay for the right A formal agreement documenting Go to 62
to your accommodation. the life interest
An informal agreement, no rent paid Go to 62
No Go to next question
An informal agreement to live at a Go to 58
Yes Amount of entry contribution child’s home and pay rent
$ Other Give details below
Provide a copy of the signed contract or
agreement.

44 Did you (and/or your partner) make a gift and/or loan in addition Go to 58
to the entry contribution?
No Go to 52 48 What are the details of the person or organisation that was paid
Yes Go to next question money or assets were transferred to?
Full name (of the person or organisation)
45 What was the additional amount paid as a gift and/or loan?
Amount of gift
Address
$
Amount of loan
$
Postcode
Go to 52

49 What was the amount paid?

$

50 What (if any) assets were transferred?

51 What was the market value of assets transferred?

$

Mod(AC).2011
7 of 10
 Living with other people 53 Do you (and your partner) share your accommodation with one or
more of your children who receive a Centrelink payment, ABSTUDY
or a service pension but they do not receive Rent Assistance?
Sharing your accommodation means that you have the right
to use a kitchen, bedroom or bathroom with one or more No
persons. This includes all family members (except children Yes
which you are paid family assistance for), people who
regularly stay at your accommodation and people who work
away from home, for example, truck drivers, miners, flight Paying for accommodation
attendants or members of the armed forces.
54 Do you (and your partner) pay board and/or lodgings?
Board means you (and your partner) are provided with some
52 Do you (and your partner) share your accommodation with regular meals.
other people?
Lodgings means the amount you (and your partner) pay for
No Go to next question your accommodation.
Yes Give details below
No Go to 56
1 Person’s name Age
Yes Go to next question

Date they moved in Relationship to you 55 Can you separate the amounts you (and your partner) pay for
board and/or lodgings?
/ /
No Total board and lodgings charged per
Their share of the rent/lodgings Do they own the home? day, week, fortnight, 4 weeks or calendar month
$ per No Yes $ per
Go to 57
2 Person’s name Age
Yes Amount paid for board (meals) per
day, week, fortnight, 4 weeks or calendar month
Date they moved in Relationship to you
$ per
/ /
Amount paid for lodgings (accommodation only) per
Their share of the rent/lodgings Do they own the home? day, week, fortnight, 4 weeks or calendar month
$ per No Yes $ per
Go to 57
3 Person’s name Age

56 What is the amount you (and your partner) pay per day, week,
Date they moved in Relationship to you fortnight, 4 weeks or calendar month, for example, rent,
/ / maintenance or site fees?
This would be the total you (and your partner) pay for the
Their share of the rent/lodgings Do they own the home? property minus any subsidy/rebate, rent amount claimed as
$ per No Yes a business expense for taxation purposes or contribution
from another person or organisation.
4 Person’s name Age
$ per

Date they moved in Relationship to you

57 On what date did you (and your partner) start paying these fees?
/ /
/ /
Their share of the rent/lodgings Do they own the home?
$ per No Yes

If you need more space, provide a separate sheet with details.

Mod(AC).2011
8 of 10
58 What type of accommodation do you (and your partner) live in? 62 Have you sold your former home?
Boarding house/hostel/private hotel, Go to 60 Your pension or allowance may be affected if you sell your
hospital or disability housing former home.
Private house or townhouse/unit/flat No Go to 64
Community housing Yes Give details below
Defence housing Go to next question
Name of Agent/Solicitor who sold your home
Caravan/cabin/mobile home
Boat
What was the date of settlement?
Other Give details below
/ /
What was the net amount that you received from the sale?
Go to next question
$

59 What is the total amount being charged per How have you used (or intend to use) the proceeds of the sale?
day, week, fortnight, 4 weeks or calendar month?
$ per

60 Details of your landlord, authorised agent or person you (and/or

your partner) pay rent to Provide documents to verify the details of the sale
(for example, settlement statement).
Full name

Address 63 Do you intend to purchase or construct a new home?

No Go to next question
Yes Give details below
Expected date of completion
Postcode / /
Contact phone number What amount do you intend to use from the proceeds of the
sale of your principal home for your new home?
$

61 Do you (and/or your partner) have a formal lease or tenancy

agreement?
No Go to next question
Yes Provide a full copy of your signed lease or
tenancy agreement.

Mod(AC).2011
9 of 10
64 Which of the following forms and documents are you (and/or Privacy notice
your partner) providing with this form?
Where you are asked to supply documents, provide original 65 You need to read this
documents. In some circumstances, copies may be accepted Privacy and your personal information
as detailed in the below checklist.
The privacy and security of your personal information is
If you are not sure, check the question to see if you should important to us, and is protected by law. We need to collect
provide the documents. this information so we can process and manage your
applications and payments, and provide services to you. We
Evidence of your need for a substantial level of care only share your information with other parties where you
(If you answered question 16) have agreed, or where the law allows or requires it. For more
information, go to servicesaustralia.gov.au/privacy
www.

Evidence of why the person you care for requires a

substantial level of care
(If you answered question 18)
Declaration
Tax returns and a list of the expenses involved in letting
the property 66 I declare that:
(If you answered Yes at question 20) • the information I have provided in this form is complete and
Real estate details (Mod R) form correct.
(If you answered Yes at question 26 and/or question 27) I understand that:
• if submitting this document as part of a claim, the claim may
Business details (Mod F) form and not be accepted unless supporting documents are lodged
Real estate details (Mod R) form at the same time as the claim. The only exception will be if I
(If you answered Yes at question 28) am waiting for medical evidence or other documents from
a third party.
Private Trust (Mod PT) form
• Centrelink can make relevant enquiries to make sure I
(If you answered Yes at question 29)
receive the correct entitlement.
Private Company (Mod PC) form • giving false or misleading information is a serious offence.
(If you answered Yes at question 30)
Your signature
Copy of signed accommodation agreement(s)
(If you answered Yes at question 39) On completion of this form,
Copy of the signed contract or agreement print and sign by hand
(If you answered Yes at question 43)
Date
Full copy of your signed lease or tenancy agreement
(If you answered Yes at question 61) / /
Document to verify the details of the sale of
your former home Your partner’s signature
(If you answered Yes at question 62)
On completion of this form,
print and sign by hand

Date
/ /

Returning this form

Return this form and any supporting documents:
• online using your Centrelink online account. For more
information, go towww.

servicesaustralia.gov.au/submitdocumentsonline
• in person at one of our service centres, if you are unable to use
your Centrelink online account.

Print Clear

Mod(AC).2011
10 of 10