Locked Bag 7834 Canberra Bc, ACT 2610
Date of Issue
11 July 2016
Your Reference Number
CLK2SS054 J246403363002
305 269 740J
Post this form to:
PO Box 7800
Canberra Bc ACT 2610
Mr Alvin A Ng
3a Five Crown Gr
DONCASTER EAST VIC 3109
SS054.1412(Page 1 of 6 )
Renewing your
Health Care Card
Purpose of this form
The information asked for on this form will be used to decide if you are still eligible for a Health Care Card.
You can renew your Health Care Card online. Go to our [Link]/centrelink and select Customer online accounts.
Returning your form
Check that all required questions are answered and that the form is signed and dated.
If you are returning this form and any supporting documents, you need to do thiswithin 21 days so we can process your application or
claim. If you cannot do this within 21 days, contact us for extra time. If extra time is required, you must contact us at the earliest possible
date to make an arrangement.
You can return this form and/or any supporting documents:
online - submit your documents online. For more information about how to lodge documents online, go to
[Link]/submitdocumentsonline
by post
in person - if you are unable to submit this form and any supporting documents online or by post, you can provide them in person
to one of our Service Centres.
Income limit
You will get a new Health Care Card if your (and your partners) income in the 8 weeks ending on
11 JULY 2016 is less than $ 4288.00.
Note: Your income limit may change if your personal circumstances have changed, for example, if you have become partnered
(married, registered partner or de facto of the opposite-sex or same-sex) since lodging your last claim.
If you do not complete this form and send it back you will not get a new Health Care Card.
If you are partnered, your partner must also answer the questions and sign the form.
1/1-1
Renewing your Health Care Card SS054.1412
(Page 2 of 6 )
Personal Details
1
Has your address changed from the above address?
No
Yes
What is your new address?
Postcode
Are you partnered?
No
Yes
Partners full name?
Do you have any dependent children?
No
Yes
Have the details you previously provided to the Australian Government Department
of Human Services about your dependent child(ren) changed in the last 8 weeks?
No
Full name
Please provide details below.
If there is not enough space, please attach a separate list.
Your dependent child
A full-time student
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Are you or your children receiving an income tested Australian Government payment (other than Family Tax Benefit) or
have you claimed such a payment (eg. Youth Allowance, ABSTUDY, or a Service Pension)?
No
Yes
Yes
Name
Type of payment
Are you enrolled in, or do you intend to enrol in a course of secondary studies?
A secondary course is a course of study approved by the Department of Education. This usually means you are doing the equivalent of
full time year 10, 11 or 12 studies.
No
Yes
If yes, you will need to complete and attach a Study details form (Mod St)
if you have not already provided this to us. If you do not have this form, go to our website
[Link]/forms
Income details
6
Self-employed
YOU
Are you (or your partner) self-employed
(such as a primary producer, sub-contractor,
or in your own business)?
No
Yes
No
Yes
If Yes, state net income from self-employment for the last
financial year.
If Yes, you must provide:
last available tax notice of assessment
last available tax return
evidence of current income from your business.
Net income means the amount left after business deductions
allowed under social security law, but before tax. Net income
must include amounts you paid into a personal
superannuation fund for which you can claim a tax deduction
on your individual tax return.
$
160713 BCH - 104801
YOUR PARTNER
BL- 2
Income details continued
7
Renewing your Health Care Card SS054.1412
(Page 3 of 6 )
Earned or received income
YOU
Did you (or your partner) earn or receive an income
from ANY source during the past 8 weeks?
No
Do NOT include any Parental Leave Pay, Dad and Partner
Pay or funding from the National Disability Insurance Scheme.
If Yes, state source of income (e.g. employer name, compensation,
income from boarders or lodgers, annuities or regular gifts or
payments from government departments other than
the Department of Human Services).
If Yes, you must provide:
payslips for the last 8 weeks (if you received an amount for
Parental Leave Pay and your employer does not show these
amounts separately on your payslips you must write Includes
Parental Leave Pay clearly on your payslips), or
a letter from your employer stating gross wages for
the last 8 weeks (including voluntary superannuation
contributions such as amounts salary sacrificed to a super
fund but NOT including Parental Leave Pay amounts), or
if compensation, annuities or regular gifts - papers
which show who pays it and how much.
Note: Letters and payslips must have your employers
name and address on them.
YOUR PARTNER
Yes
No
Yes
Gross amount received for the last 8 weeks
$
If you receive income from more than 1 source, please
attach a separate list.
Note: The last 8 weeks referred to above is the 8
week period ending on the date printed under the
heading Income limit located at the start of this form.
8
Do you (or your partner) receive any fringe benefits
provided by an employer (e.g. use of a car as part of
a salary package, rent/mortgage paid)?
Fringe benefits means a benefit received as part
of earned income but not as a wage or salary.
YOU
No
YOUR PARTNER
Yes
No
Yes
If Yes, attach details that indicate the type of fringe benefit
and its value, and whether or not the amount is grossed-up
or not grossed up
Savings accounts
Give details below of all accounts held by you (and/or
your partner) in banks, building societies or credit unions.
Attach proof of all account balances
(e.g. ATM slip, statements, passbooks).
Include savings accounts, cheque accounts, term
deposits, joint accounts, accounts you hold in trust or
under any other name, or money held in church or
charitable development funds.
Accounts and term deposits outside Australia should be
included, with the current balance in the type of currency
in which it is invested. We will convert this into
Australian dollars.
Do NOT include shares, managed investments or an account
used exclusively for funding from the National Disability
Insurance Scheme.
Name of bank, building Account number
society or credit union (this may not be
your card number)
Type of account Balance of
account
10 Shares
Currency if not
AUD
Partners
share
YOU
Do you (and/or your partner) own any shares, options,
rights, convertible notes or other securities LISTED on
an Australian Stock Exchange
(e.g. ASX, NSX, APX or Chi-X) or a stock exchange outside
Australia?
Your
share
YOUR PARTNER
No
Yes
No
Yes
If Yes, give details below
Attach the latest statement for each share holding.
Include shares traded in exempt stock markets.
Do NOT include managed investments.
Name of company
Number of shares ASX code (if known) Country if not
or other securities
Australia
Your
share
Partners
share
%
%
2/1-1
%
%
Income details continued
Renewing your Health Care Card SS054.1412
11 Do you (and/or your partner) own any shares, options
or rights in PUBLIC companies, NOT listed on a stock
exchange?
Do NOT include managed investments.
(Page 4 of 6 )
YOU
YOUR PARTNER
No
Yes
If Yes, give details below
No
Yes
Attach the latest statement detailing your share holding for
each company (if available).
Name of company
Type of shares
Number of shares
12 Managed investments
Current market
value
YOU
YOUR PARTNER
No
Include:
investment trusts
personal investment plans
life insurance bonds
friendly society bonds.
Do NOT include:
conventional life insurance policies
funeral bonds, superannuation or rollover investments.
APIR code is commonly used by fund managers to
identify individual financial products.
If Yes, give details below
Name of product
(e.g. investment
trust)
Partners
share
Do you (and/or your partner) have any managed
investments in and/or outside Australia?
Name of company
Your
share
Yes
No
Yes
Attach a document which gives details (e.g. certificate with
number of units or account balance) for each investment.
Type of product/
Number
option (e.g.
of units
balanced, growth)
APIR code
(if known)
Current Market Currency Your
value
if not AUD share
Partners
share
13 Superannuation YOU should answer this question ONLY if you are over age pension age or claiming Age Pension. YOUR
PARTNER should answer this question ONLY if they are over age pension age or claiming Age Pension.
The qualifying age for Age Pension is currently 65 years.
From 1 July 2017, the qualifying age for Age pension will increase from 65 years to 65 years and 6 months. The
qualifying age will then rise by 6 months every 2 years, reaching 67 years by 1 July 2023. See table below.
Date of Birth
1 July 1952 to 31 December 1953
1 January 1954 to 30 June 1955
1 July 1955 to 31 December 1956
From 1 January 1957
Qualifying age at
65 years and 6 months
66 years
66 years and 6 months
67 years
Do you (or your partner) have any money invested in
superannuation where the fund is still in accumulation
phase and not paying a pension?
YOU
Include:
superannuation funds such as retail, industry, corporate
or employer and public sector
retirement savings accounts
Self Managed Superannuation Funds (SMSF) and Small
APRA Funds (SAF) if the funds are complying.
If Yes, give details below
Attach the latest statement for each superannuation investment.
If you are a SMSF or SAF, attach the financial returns and member
statement for the fund.
Name of institution/fund manager
Name of fund
No
Date of
joining/investment
YOUR PARTNER
Yes
Yes
Current market Owned by
value
$
160713 BCH - 104801
No
You
Your partner
BL- 4
Income details continued
Renewing your Health Care Card SS054.1412
14 Trusts
YOU
Are you or have you (and/or your partner) been involved
in a private trust in any of the ways detailed below?
You (and/or your partner) may be, or have been involved
in a trust as:
a trustee
an appointor
a beneficiary
OR have:
made a loan to a private trust
made a gift of cash, assets, or private property to a private
trust in the last 5 years
relinquished control of a private trust in the last 5 years
a private annuity
a life interest
an interest in a deceased estate.
A private trust includes a non-complying Self Managed
Superannuation Fund or a non-complying Small APRA Fund.
15 Companies
No
(Page 5 of 6 )
YOUR PARTNER
Yes
No
Yes
If Yes, you (and/or your partner) will need to complete and
attach a Private Trust form (Mod PT) if you have not already
provided this to us. If you do not have this form, go to our
website [Link]/forms
YOU
YOUR PARTNER
Are you or have you (and/or your partner) been involved
in a private company in any of the ways detailed below?
No
You (or your partner) may be, or have been in the last 5
years:
a director of a company
a shareholder of a company
OR have:
made a loan to a private company
transferred shares in a private company
made a gift of cash, assets or property to a private company.
If Yes, you (and/or your partner) will need to
complete and attach a Private Company form (Mod
PC) if you have not already provided this to us. If you
do not have this form, go to our website
[Link]/forms
16 Lump sum payments
In the last 12 months, have you (or your partner)
received a lump sum payment that you have not
already advised on this form?
Do NOT include:
compensation, insurance or damages lump sum payments
funding from the National Disability Insurance Scheme.
Type of lump sum
Who paid it?
Yes
No
YOU
YOUR PARTNER
No
Yes
If Yes, give details below
No
Amount paid
Date paid
Yes
Who received this lump sum
payment?
$
17 Compensation, insurance and/or damages
Yes
You
YOU
Your partner
YOUR PARTNER
Since you last claimed or renewed your Low Income
Health Care Card have you (or your partner) CLAIMED
or are you ABLE TO CLAIM compensation, insurance
and/or damages?
No
Include:
workers compensation/damages as a result of a work injury
third party damages as a result of a motor vehicle accident
personal accident and sickness insurance or income
replacement/protection insurance
sporting injury compensation
public liability compensation
medical negligence compensation
damages paid to victims of crime or as a result of criminal
injuries.
If Yes, you (and/or your partner) will need to complete and
attach a Compensation and damages form (Mod C) if you
have not already provided this to us. If you do not have this
form, go to our website [Link]/forms
3/1-1
Yes
No
Yes
Income details continued
Renewing your Health Care Card SS054.1412
18 Gifts
YOU
In the last 5 years, have you (or your partner) given
away, sold for less than their value, or surrendered
a right to, any cash, assets, property or income?
No
(Page 6 of 6 )
YOUR PARTNER
Yes
No
Yes
If Yes, give details below
Include forgiven loans and shares in private companies.
Note: If you give away assets or sell them for less than their
value your claim for a Health Care Card could be affected.
What you gave away or sold for less
than its market value (e.g. money,
car, second home, land, farm)
Date given
or sold
What it
was worth
What you
got for it
Your
share
19 Other income
Partners
share
YOU
Do you (or your partner) receive income from
property or other assets not already mentioned
above (e.g. rent payments)?
Do NOT include funding from the National Disability
Insurance Scheme.
Was this gift to a
Special Disability
Trust (SDT)?
No
Yes
YOUR PARTNER
No
Yes
No
Yes
If Yes, you must provide a copy of last available tax return
or other papers which show income and mortgage details.
If Yes, state annual income
$
20 Income streams
YOU
YOUR PARTNER
Do you (and/or your partner) receive income from any
income stream products?
No
Yes
If Yes, give details below
No
An income stream product is a regular series of
payments which may be made for a lifetime or a fixed
period by:
a financial institution
a retirement savings account
a superannuation fund
a Self Managed Superannuation Fund (SMSF)
a Small APRA Fund (SAF)
You (and/or your partner) will need to attach a
Details of income stream product form (SA330) or a
similar schedule, for each income stream product.
The form or similar schedule must be completed by your
product provider or the trustee of the Self Managed
Superannuation Fund (SMSF) or Small APRA Fund (SAF)
or the SMSF administrator.
Yes
If you do not have this form, go to our website
Types of income streams include:
[Link]/forms
account-based pension (also known as allocated pension)
market linked pension (also known as term allocated
pension)
annuities
defined benefit pension (e.g. CompSuper pension, State
Super pension)
superannuation pension (non-defined benefit).
Name of product
Type of income stream
Product reference
Commencement
Your
provider/SMSF/SAF
number
date
share
Partners
share
%
21 Permission to enquire
YOU
Do you give permission for your
partner to discuss your Health Care
Card with us?
You can change this authority at any time.
No
YOUR PARTNER
Yes
No
Yes
22 IMPORTANT INFORMATION
Privacy and your personal information
Your personal information is protected by law, including thePrivacy 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 for the purposes of research, investigation or where you have
agreed or it is required or authorised by law.
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 [Link]/privacy or by requesting a copy from the department.
Statement
I declare that
I understand that
the information I have provided in this form is complete and correct.
giving false or misleading information is a serious offence.
Your signature
Your partners signature (if applicable)
Date
Date
160713 BCH - 104801
BL- 6
