Claim for a Commonwealth Seniors Health Card
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Claim for a Commonwealth
Seniors Health Card
When to use this form Use this form to claim a Commonwealth Seniors Health Card for yourself and your partner.
The Commonwealth Seniors Health Card provides you with access to Pharmaceutical
Benefits Scheme (PBS) prescription medicines, certain Medicare services and specific
rail travel, at the concessional rate. The card also entitles you to Seniors Supplement if
you qualify. State, territory and local governments, and some private providers, may offer
additional concessions at their own discretion.
You should have received the booklet Information you need to know about your claim
for Commonwealth Seniors Health Card, Low Income Health Care Card, Foster Child
Health Care Card and Ex-Carer Allowance (Child) Health Care Card with this form.
In this claim, this booklet will be referred to as the Information Booklet. If you do not have
this booklet, go to our website humanservices.gov.au/seniorshealthcard or call us on
www.
132 300.
Who can claim a Note: Do not lodge this claim until you have reached age pension age (refer to the Information
Commonwealth Seniors Booklet for the qualifying age for Commonwealth Seniors Health Card). You must be age
Health Card pension age to make a claim for a Commonwealth Seniors Health Card.
You cannot receive a Commonwealth Seniors Health Card if you are already receiving any
of the following:
• Centrelink pension or benefit
• Department of Veterans’ Affairs Service pension
• Department of Veterans’ Affairs Age Pension
• Department of Veterans’ Affairs Income Support supplement
• Department of Veterans’ Affairs Commonwealth Seniors Health Card.
If you have been receiving any of the above assistance and it will be cancelled soon,
do not lodge your claim for the Centrelink Commonwealth Seniors Health Card until after
the cancellation date.
If your partner is receiving an entitlement from the Department of Veterans’ Affairs, you may
still be entitled to a Commonwealth Seniors Health Card from the Australian Government
Department of Human Services and both of you should complete this claim form. Contact
the Department of Veterans’ Affairs for information on what you are receiving and what
further entitlements you may have from them.
The Commonwealth Seniors Health Card does not cover dependants and/or partners, only
the cardholder. If you have dependants, or a partner who is not eligible for a Commonwealth
Seniors Health Card, it is important you read the section on ‘Low Income Health Care Card’
in the Information Booklet.
Online Services Lodging your claim online is easy. By accessing our Online Services you can complete your
claim for the Commonwealth Seniors Health Card online in the comfort of your own home
and at a time that is convenient to you.
You can access your Centrelink, Medicare and Child Support Online Services through myGov.
myGov is a fast simple way to access a range of government services online with one
username, one password, all from one secure location. To create a myGov account, go to www.
my.gov.au
SA296.1403 1 of 18For more information Go to our website humanservices.gov.au/seniorshealthcard or call us on 132 300
www.
or visit one of our Service Centres.
To speak to us in languages other than English, call 131 202.
Note: Call charges apply – calls from mobile phones may be charged at a higher rate.
If you have a hearing TTY service Freecall™ 1800 810 586. A TTY phone is required to use this service.
or speech impairment
Interpreters and If you need an interpreter or translation of any documents for our business, we can arrange
translations this for you free of charge.
What else you will You will need to provide proof of identity. There is a complete list of acceptable documents
need to provide in the Information Booklet.
This form tells you which other documents you need to provide to support your claim.
Depending on your circumstances, you may have to fill in other forms.
Filling in this form • Please use black or blue pen.
• Print in BLOCK LETTERS.
• Mark boxes like this with a or .
• Where you see a box like this Go to 5 skip to the question number shown. You do not
need to answer the questions in between.
Returning your form(s) Check that you have answered all the questions you need to answer and that you (and your
partner) have signed and dated this form.
If you return required documents (and your claim form):
• online – you can submit your documents online if you are registered for Online Services.
• by post – we will sight and record your documents, which may include copying, and
return the originals to you by registered post.
• in person – we will sight and record your documents, which may include copying, and
return the originals to you.
Return this form, all additional documents and any other forms you are required to complete
to one of our Service Centres or online within 14 days to make sure you qualify from the
earliest date possible. You cannot lodge your claim form before reaching age pension age
or while you are entitled to any of the assistance listed on page 1.
If you cannot return all the forms or documents within 14 days, contact us for extra time.
For more information on how to access Online Services or how to lodge documents online,
go to humanservices.gov.au/submitdocumentsonline
www.
SA296.1403 2 of 18Please read this before completing this claim form.
Under social security law, claims for the Commonwealth
Seniors Health Card cannot be lodged before a person has
reached age pension age. Please lodge this form either on, or
after, the date you reach age pension age. Please see the
Information Booklet for more details on the qualifying age
for the Commonwealth Seniors Health Card.
1 Do you need an interpreter when dealing with us?
This includes an interpreter for people who have a hearing
or speech impairment.
No Go to 3
Yes Go to next question
2 What is your preferred spoken language?
3 What is your preferred written language?
4 Do you have a partner?
No Go to 7
Yes Go to next question
5 Is your partner also claiming the Commonwealth Seniors
Health Card?
No You will still need to give your partner's personal
and income details. You will not be required to
give proof of your partner’s identity.
Yes If you are both eligible you will both get
Commonwealth Seniors Health Cards.
CLK0SA296 1403
SA296.1403 3 of 186 Please read this before answering the following questions.
Please complete the left hand column for yourself.
Your partner (if you have one) should complete ALL questions in the right hand column, unless instructed otherwise, even if
they are not claiming a Commonwealth Seniors Health Card. This will enable your entitlement to be assessed.
You Your partner
7 Do you receive a Centrelink pension or benefit? Do you receive a Centrelink pension or benefit?
No Go to next question No Go to next question
Yes You cannot get a Commonwealth Seniors Yes Your Centrelink Reference Number (if known)
Health Card.
You need to complete this form if you have a You cannot get a Commonwealth Seniors Health Card.
partner and your partner is also claiming a
You only need to complete this form if your
Commonwealth Seniors Health Card.
partner is also claiming a Commonwealth
If your pension or benefit will be cancelled Seniors Health Card.
soon, do not lodge this claim until after the
If your pension or benefit will be cancelled
cancellation date.
soon, do not lodge this claim until after the
Go to 10 cancellation date.
Go to 10
8 Do you receive a Service Pension or income support Do you receive a Service Pension or income support
supplement from the Department of Veterans’ Affairs? supplement from the Department of Veterans’ Affairs?
No Go to next question No Go to next question
Yes Your Department of Veterans’ Affairs Service Number
Yes You cannot get a Commonwealth Seniors
Health Card.
You need to complete this form if you have a You cannot get a Commonwealth Seniors Health Card.
partner and your partner is also claiming a
You only need to complete this form if your
Commonwealth Seniors Health Card.
partner is also claiming a Commonwealth
If your Service Pension or income support Seniors Health Card.
supplement will be cancelled soon, do not lodge
If your Service Pension or income support
this claim until after the cancellation date.
supplement will be cancelled soon, do not lodge
Go to 10 this claim until after the cancellation date.
Go to 10
9 Do you have a Department of Veterans' Affairs Do you have a Department of Veterans' Affairs
Commonwealth Seniors Health Card? Commonwealth Seniors Health Card?
No Go to next question No Go to next question
Yes Your Centrelink Reference Number (if known)
Yes You cannot get a Commonwealth Seniors
Health Card.
You need to complete this form if you have a Your Department of Veterans’ Affairs Service Number
partner and your partner is also claiming a
Commonwealth Seniors Health Card.
If your Department of Veterans’ Affairs You cannot get a Commonwealth Seniors Health Card.
Commonwealth Seniors Health Card will be
cancelled soon, do not lodge this claim until You only need to complete this form if your
after the cancellation date. partner is also claiming a Commonwealth
Seniors Health Card.
Go to next question
If your Department of Veterans’ Affairs
Commonwealth Seniors Health Card will be
cancelled soon, do not lodge this claim until
after the cancellation date.
Go to next question
SA296.1403 4 of 18You Your partner
10 Your name Your name
Mr Mrs Miss Ms Other Mr Mrs Miss Ms Other
Family name Family name
First given name First given name
Second given name Second given name
11 Have you ever used or been known by any other name Have you ever used or been known by any other name
(e.g. name at birth, maiden name, previous married name, (e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)? Aboriginal or tribal name, alias, adoptive name, foster name)?
No Go to next question No Go to next question
Yes Give details below Yes Give details below
1 Other name 1 Other name
Type of name (e.g. name at birth) Type of name (e.g. name at birth)
2 Other name 2 Other name
Type of name (e.g. maiden name) Type of name (e.g. maiden name)
If you have more than 2 other names, attach a separate If you have more than 2 other names, attach a separate
sheet with details. sheet with details.
12 Your sex Your sex
Male Male
Female Female
13 Your date of birth Your date of birth
/ / / /
Attach an original document as proof of your date If you are claiming Commonwealth Seniors Health
of birth. Card, attach an original document as proof of your
date of birth.
SA296.1403 5 of 18You Your partner
14 Your permanent address Your permanent address
Postcode Postcode
15 Your postal address (if different to above) Your postal address (if different to above)
Postcode Postcode
16 Please read this before answering the following question. Please read this before answering the following question.
If you provide an email or mobile phone number, you If you provide an email or mobile phone number, you
MUST read the Terms and Conditions for Electronic MUST read the Terms and Conditions for Electronic
Messaging (SMS or email) in the Information Booklet. Messaging (SMS or email) in the Information Booklet.
Your contact details Your contact details
Home phone number ( ) Home phone number ( )
Is this a silent number? No Yes Is this a silent number? No Yes
Mobile phone number Mobile phone number
Fax number ( ) Fax number ( )
Work phone number ( ) Work phone number ( )
Alternative phone number ( ) Alternative phone number ( )
Email Email
@ @
17 Questions 17 and 18 are optional and will not affect your Questions 17 and 18 are optional and will not affect your
Commonwealth Seniors Health Card. If you do answer, Commonwealth Seniors Health Card. If you do answer,
the information will help us to continue to improve the information will help us to continue to improve
services to Aboriginal, Torres Strait Islander Australians services to Aboriginal, Torres Strait Islander Australians
and Australian South Sea Islanders. and Australian South Sea Islanders.
Australian South Sea Islanders are the descendants of Australian South Sea Islanders are the descendants of
Pacific Islander labourers brought from the Western Pacific Islander labourers brought from the Western
Pacific in the 19th Century. Pacific in the 19th Century.
Are you of Aboriginal or Torres Strait Islander Australian Are you of Aboriginal or Torres Strait Islander Australian
origin? origin?
If you are of both Aboriginal and Torres Strait Islander If you are of both Aboriginal and Torres Strait Islander
Australian origin, please tick both ‘Yes’ boxes. Australian origin, please tick both ‘Yes’ boxes.
No No
Yes – Aboriginal Australian Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian Yes – Torres Strait Islander Australian
18 Are you of Australian South Sea Islander origin? Are you of Australian South Sea Islander origin?
No No
Yes Yes
SA296.1403 6 of 18You Your partner
19 Please read this before answering the following question.
We recognise both opposite-sex and same-sex
relationships. This includes de facto relationships and
relationships registered under state or territory law.
Select ONE option below that best describes your
current relationship status.
What is your CURRENT relationship status?
Married Go to 20
Registered relationship
(opposite-sex or same-sex relationship
registered under state or territory law) Go to 20
Partnered
(living together in an opposite-sex or
same-sex relationship, including de facto) Go to 21
Separated
(previously lived with an opposite-sex or
same-sex partner, including in a marriage,
registered or de facto relationship) Go to 26
Divorced Go to 26
Widowed
(previously partnered with an opposite-sex
or same-sex partner, including in a
marriage, registered or de facto relationship) Go to 26
Never married or lived with a partner Go to 27
20 What is your date of marriage or relationship registration?
/ / Go to 22
21 When did you and your partner start living together as a
member of a couple?
/ /
22 Do you currently live in the same home as your partner?
No Go to next question
Yes Go to 25
23 Why are you not living with your partner?
Partner’s illness
Your illness
Partner in prison
Partner’s employment
Other Give details below
SA296.1403 7 of 18You Your partner
24 Period not living with your partner
From / /
To / / OR indefinite
Go to 27
25 Do you give permission for your partner to discuss your Do you give permission for your partner to discuss your
entitlements with us? entitlements with us?
You can change this authority at any time. You can change this authority at any time.
No No
Go to 27 Go to 27
Yes Yes
26 Date divorced, widowed or separated
/ /
27 Do you want to authorise another person or organisation to Do you want to authorise another person or organisation to
make enquiries and/or act on your behalf? make enquiries and/or act on your behalf?
No Go to next question No Go to next question
Yes You will need to complete and attach an Yes You will need to complete and attach an
Authorising a person or organisation Authorising a person or organisation
to enquire or act on your behalf form to enquire or act on your behalf form
(SS313). If you do not have this form, (SS313). If you do not have this form,
go to our website
www. go to our websitewww.
humanservices.gov.au/nominees or call humanservices.gov.au/nominees or call
us on 132 300. us on 132 300.
28 Please read this before answering the questions about tax. Please read this before answering the questions about tax.
You are not breaking the law if you do not give us your You are not breaking the law if you do not give us your
tax file number, but if you do not provide it to us, or tax file number, but if you do not provide it to us, or
authorise us to get it from the Australian Taxation Office, authorise us to get it from the Australian Taxation Office,
you (and your partner if you have one) may not be you (and your partner if you have one) may not be
granted a Commonwealth Seniors Health Card. granted a Commonwealth Seniors Health Card.
In giving us your tax file number in relation to this claim In giving us your tax file number in relation to this claim
you authorise us to use your tax file number for other you authorise us to use your tax file number for other
social security payments and services in future where social security payments and services in future where
necessary. necessary.
Have you given us your tax file number before? Have you given us your tax file number before?
No Go to next question No Go to next question
Not sure Go to next question Not sure Go to next question
Yes Go to 30 Yes Go to 30
29 Do you have a tax file number? Do you have a tax file number?
No Please call us on 132 300 No Please call us on 132 300
Yes Your tax file number Yes Your tax file number
SA296.1403 8 of 18You Your partner
30 Please read this before answering the following question. Please read this before answering the following question.
'Permanently' means you normally live in Australia on 'Permanently' means you normally live in Australia on
a long-term basis. Holidays or short trips outside a long-term basis. Holidays or short trips outside
Australia would not affect this. Australia would not affect this.
Are you living in Australia permanently? Are you living in Australia permanently?
No No
Yes Yes
31 Have you lived or travelled outside Australia since Have you lived or travelled outside Australia since
1 September 1994, including short trips and holidays? 1 September 1994, including short trips and holidays?
The answer to this question may enable us to access The answer to this question may enable us to access
electronic records held by Australia’s immigration electronic records held by Australia’s immigration
department since 1 September 1994. These records department since 1 September 1994. These records
will help us to verify your Australian residence on your will help us to verify your Australian residence on your
behalf and assist in processing your claim. behalf and assist in processing your claim.
No Go to next question No Go to next question
Yes Give details below Yes Give details below
Passport number Passport number
Country of issue Country of issue
32 Are you an Australian citizen who was born in Australia? Are you an Australian citizen who was born in Australia?
No You will need to provide proof of your No You will need to provide proof of your
Australian residence status Australian residence status
(e.g. citizenship papers, passport or (e.g. citizenship papers, passport or
other documentation). other documentation).
Go to next question Go to next question
Yes Go to 42 Yes Go to 42
33 What is your country of birth? What is your country of birth?
34 When did you start living in Australia? When did you start living in Australia?
/ / / /
35 Did you start living in Australia before 1965? Did you start living in Australia before 1965?
No Go to next question No Go to next question
Yes Give details below Yes Give details below
Name of the ship or airline on which you arrived Name of the ship or airline on which you arrived
Name of the place where you first arrived/disembarked Name of the place where you first arrived/disembarked
What was your name when you first arrived in Australia? What was your name when you first arrived in Australia?
SA296.1403 9 of 18You Your partner
36 What is your country of citizenship? What is your country of citizenship?
Australia Date granted Australia Date granted
/ / / /
Go to 42 Go to 42
Other Country of citizenship Other Country of citizenship
37 What type of visa did you arrive on? What type of visa did you arrive on?
New Zealand passport Go to 39 New Zealand passport Go to 39
(special category visa) (special category visa)
Permanent Go to next question Permanent Go to next question
Temporary Go to next question Temporary Go to next question
Unknown (e.g. arrived Go to 39 Unknown (e.g. arrived Go to 39
on parent’s passport) on parent’s passport)
38 Your visa details on arrival Your visa details on arrival
Visa sub class Date visa granted Visa sub class Date visa granted
/ / / /
39 Has your visa changed since you arrived in Australia? Has your visa changed since you arrived in Australia?
No Go to next question No Go to next question
Yes Most recent visa details Yes Most recent visa details
Visa sub class Date visa granted Visa sub class Date visa granted
/ / / /
40 Are you a refugee or former refugee? Are you a refugee or former refugee?
No No
Yes Yes
41 Did either of your parents arrive on a refugee or Did either of your parents arrive on a refugee or
humanitarian visa? humanitarian visa?
No No
Yes Yes
SA296.1403 10 of 18You Your partner
42 Please read this before answering the following question. Please read this before answering the following question.
We need to know if you have lived in countries other We need to know if you have lived in countries other
than Australia from birth through to the present. than Australia from birth through to the present.
‘Lived’ means where you/your family made your home ‘Lived’ means where you/your family made your home
or spent a long period of time – it does not include or spent a long period of time – it does not include
places you visited. places you visited.
Except for short trips or holidays, have you EVER lived Except for short trips or holidays, have you EVER lived
outside Australia? outside Australia?
No Go to next question No Go to next question
Yes List ALL countries, INCLUDING AUSTRALIA, you Yes List ALL countries, INCLUDING AUSTRALIA, you
have lived in SINCE BIRTH. have lived in SINCE BIRTH.
If you were born outside Australia, include the If you were born outside Australia, include the
country where you were born. country where you were born.
Include the periods you have lived in each country. Include the periods you have lived in each country.
Do NOT include short trips or holidays. Do NOT include short trips or holidays.
1 Country of residence 1 Country of residence
From / / To / / From / / To / /
2 Country of residence 2 Country of residence
From / / To / / From / / To / /
3 Country of residence 3 Country of residence
From / / To / / From / / To / /
4 Country of residence 4 Country of residence
From / / To / / From / / To / /
5 Country of residence 5 Country of residence
From / / To / / From / / To / /
If you require more space, attach a separate sheet If you require more space, attach a separate sheet
with details. with details.
SA296.1403 11 of 1843 Please read this before answering the following questions.
The applicable Commonwealth Seniors Health Card income limit is increased by $639.60 for each dependent child you have.
For the purposes of the Commonwealth Seniors Health Card income test ‘dependent child’ means:
For a young person under 16 years of age
• a young person for whom you have legal responsibility, either alone or jointly, for their day-to-day care, welfare and
development. Or, if you are not legally responsible, the young person is not a dependent child of someone else and is wholly
or substantially in your care, and
• if the young person is not in full-time education, they must not be in receipt of income above a certain limit, called the
dependency limit, and
• the young person is not receiving a social security pension or benefit, and
• if the young person is not an Australian resident, they are living with you.
For a young person between 16 and 21 years of age
• the young person is wholly or substantially dependent on you, and
• the young person's financial year income does not exceed the personal income limit, and
• the young person is not receiving a social security pension or benefit, and
• if the young person is not an Australian resident, they are living with you.
Please refer to the Information Booklet for more information about dependent children.
Go to humanservices.gov.au/seniorshealthcard or call 132 300 for the current dependency limits and personal income limits.
www.
Do you (and/or your partner) have any dependent children?
No Go to next question
Yes Give the following details of each child
If you have more than 2 dependent children, attach a separate sheet with details.
Child 1 Child 2
A Family name A Family name
First given name First given name
Second given name Second given name
B Has this child ever been known by any other names? B Has this child ever been known by any other names?
No Go to C for this child No Go to C for this child
Yes List the other names Yes List the other names
C Sex C Sex
Male Male
Female Female
D Date of birth D Date of birth
/ / / /
E Do you receive Family Tax Benefit for this child? E Do you receive Family Tax Benefit for this child?
No Attach proof of birth (e.g. birth No Attach proof of birth (e.g. birth
certificate) for this child if you have not certificate) for this child if you have not
previously provided it to us. previously provided it to us.
Yes Yes
SA296.1403 12 of 18You Your partner
44 Seniors Supplement is paid quarterly to help with Seniors Supplement is paid quarterly to help with
household costs. household costs.
A quarterly Clean Energy Supplement will also be paid A quarterly Clean Energy Supplement will also be paid
to people who get the Seniors Supplement to help manage to people who get the Seniors Supplement to help manage
the impact on the cost of living from the carbon price. the impact on the cost of living from the carbon price.
If you wish to receive Seniors Supplement, and therefore, If you wish to receive Seniors Supplement, and therefore,
the Clean Energy Supplement you must provide details the Clean Energy Supplement you must provide details
of a bank account into which the payments can be made. of a bank account into which the payments can be made.
You may choose not to receive Seniors Supplement and You may choose not to receive Seniors Supplement and
therefore, not receive the Clean Energy Supplement, but therefore, not receive the Clean Energy Supplement, but
this will not affect your eligibility for a Commonwealth this will not affect your eligibility for a Commonwealth
Seniors Health Card. Seniors Health Card.
If at any time in the future you change your mind and If at any time in the future you change your mind and
wish to receive these payments, they will commence wish to receive these payments, they will commence
from when you provide your bank account details. from when you provide your bank account details.
Refer to the Information Booklet for more information. Refer to the Information Booklet for more information.
Do you wish to receive Seniors Supplement and the Do you wish to receive Seniors Supplement and the
Clean Energy Supplement? Clean Energy Supplement?
No Go to 46 No Go to 46
Yes Go to next question Yes Go to next question
45 You must give your bank account details to get Seniors You must give your bank account details to get Seniors
Supplement and the quarterly Clean Energy Supplement. Supplement and the quarterly Clean Energy Supplement.
Where do you want your payment made? Where do you want your payment made?
The bank, building society or credit union account must be The bank, building society or credit union account must be
in your name. A joint account is acceptable. in your name. A joint account is acceptable.
Name of bank, Name of bank,
building society or building society or
credit union credit union
Branch where your Branch where your
account is held account is held
Branch number (BSB) Branch number (BSB)
Account number Account number
(this may not be (this may not be
your card number) your card number)
Account held in the name(s) of Account held in the name(s) of
46 Please read this before answering the following question. Please read this before answering the following question.
To register for the Pension Bonus Scheme, you must To register for the Pension Bonus Scheme, you must
have met the age and residence requirements for Age have met the age and residence requirements for Age
Pension before 20 September 2009. Pension before 20 September 2009.
Refer to the Information Booklet for more information Refer to the Information Booklet for more information
on how this scheme can help you. on how this scheme can help you.
If you are still working, would you like information and a If you are still working, would you like information and a
registration form for the Pension Bonus Scheme? registration form for the Pension Bonus Scheme?
No No
Yes Yes
SA319 and RT002 SA319 and RT002
SA296.1403 13 of 18You Your partner
47 News for Seniors News for Seniors
News for Seniors is a free publication produced by News for Seniors is a free publication produced by
us that keeps you informed of issues concerning us that keeps you informed of issues concerning
government benefits, services and other associated government benefits, services and other associated
support arrangements. support arrangements.
Would you like to receive News for Seniors? Would you like to receive News for Seniors?
No Go to 50 No Go to 50
Yes Go to next question Yes Go to next question
48 How would you like to receive News for Seniors? How would you like to receive News for Seniors?
Online Go to next question Online Go to next question
Mail Go to 50 Mail Go to 50
49 How would you like to be notified that the latest edition of How would you like to be notified that the latest edition of
News for Seniors is available? News for Seniors is available?
Email Email
SMS SMS
Online letters Online letters
50 The Low Income Health Care Card offers concessions for
your dependents as well as yourself. You may be eligible
for a Low Income Health Care Card if your income is
below the applicable limit.
Refer to the Information Booklet for more information.
Do you wish to apply for a Low Income Health Care Card?
No Go to next question
Yes You will need to complete and attach a
Claim for a Health Care Card form
(SS050). If you do not have this form,
go to our website www.
humanservices.gov.au/healthcarecard
or call us on 132 490.
51 Please read this before answering the following
questions.
The income details you provide can be for either of the
2 financial years preceding the current financial year.
They should be the most recent verifiable details. You
and your partner MUST provide income details for the
same financial year.
Go to next page
SA296.1403 14 of 1852 For which financial year are you (and your partner) providing /
income details?
53 Give the following income details for the financial year you have You Your partner
indicated in question 52.
A Taxable income
Attach an original Notice of Assessment issued by the Australian
$ $
Taxation Office.
OR OR OR
If your (and/or your partner’s) income was too low and you are not
required to lodge a tax return give the amount of income you (and/or
your partner) received. Only include income that is taxable and is not
income from sources requested in Parts B to E of this question. $ $
B Foreign income you did not pay Australian income tax on + +
(write the amount in Australian dollars).
Attach your tax return or other documents to verify this amount. AUD AUD
C Total net investment loss
Total net investment loss is the sum of:
Net rental property losses (see the Income tests section of your tax
return)—the amount by which the expenses incurred for a rental
property exceed the gross rental income from that property.
AND + +
Net financial investment losses (see the Income tests section of your
tax return)—the amount by which allowable deductions in respect of
financial investments exceed the gross income from those investments.
For Commonwealth Seniors Health Card purposes most deductions
allowed by the Australian Taxation Office are allowed as a deduction.
Note: You must ADD this amount even though it is a loss because such
a loss will have reduced your taxable income.
Refer to the Information Booklet.
Attach your Tax Return. $ $
D Value of employer provided benefits above $1,000. Write the total + +
amount of your employer provided benefits less the first $1,000.
Refer to the Information Booklet.
Attach relevant document(s). $ $
E Reportable superannuation contributions are the sum of your: + +
• reportable employer superannuation contributions (see the Income
tests section of your tax return), for example, salary sacrifice
contributions, and
• personal deductible superannuation contributions (see the
Supplementary section of your tax return). Contributions for which an
individual can claim a deduction on their individual tax return.
Attach payment summary and/or tax return. $ $
= =
F Total income (A + B + C + D + E = F) $ $
G Your own and your partner’s COMBINED TOTAL INCOME.
This is the adjusted taxable income we will use to work out your eligibility. $
54 Is the COMBINED TOTAL INCOME at question 53G, below or above the income limit for the Commonwealth Seniors Health Card?
Refer to the Information Booklet for the income limits.
Below the income limit Do not complete 55 and 56.
Go to 57
Above the income limit You may still be eligible if your income will be below the income limits in the current financial year.
Go to next question
SA296.1403 15 of 1855 Will your (and your partner’s) combined income in the current financial year be the same, higher or lower than it was in the
financial year you indicated at question 52?
The same
You are not eligible for a Commonwealth Seniors Health Card because your income is too high.
Higher Do NOT continue with this claim.
Lower Why will your income be lower (e.g. stopped working, previously sold significant asset(s) to pay for medical
expenses, ceased operating a business)?
You will need to attach evidence to support the reason your (and your partner’s) income will be lower.
Note: If your income is below the income limit at question 54, You Your partner
you are not required to give an estimate. Go to 57
56 Give an estimate of the income you (and your partner) expect to
receive in the current financial year.
A Estimated taxable income $ $
OR OR OR
If your (and/or your partner’s) income will be too low and you are not
required to lodge a tax return give the amount of income you (and/or
your partner) expect to receive. Only include income that is taxable and
is not income from sources requested in Parts B to E of this question. $ $
B Foreign income you do not pay Australian income tax on (write the + +
amount in Australian dollars). AUD AUD
C Total net investment loss
Total net investment loss is the sum of:
Net rental property losses—the amount by which the expenses
incurred for a rental property exceed the gross rental income from
that property.
AND + +
Net financial investment losses—the amount by which allowable
deductions in respect of financial investments exceed the gross
income from those investments.
For Commonwealth Seniors Health Card purposes most deductions
allowed by the Australian Taxation Office are allowed as a deduction.
Note: You must ADD this amount even though it is a loss because
such a loss will have reduced your taxable income.
Refer to the Information Booklet. $ $
D Value of employer provided benefits above $1,000. Write the total + +
amount of your employer provided benefits less the first $1,000.
Refer to the Information Booklet. $ $
E Reportable superannuation contributions are the sum of your: + +
• reportable employer superannuation contributions, for example,
salary sacrifice contributions, and
• personal deductible superannuation contributions. Contributions for
which an individual can claim a deduction on their individual tax
return. $ $
= =
F Total income (A + B + C + D + E = F)
$ $
G Your own and your partner’s COMBINED TOTAL INCOME.
This is the adjusted taxable income we will use to work out your eligibility. $
SA296.1403 16 of 18You Your partner
57 Which of the following forms, documents and other Which of the following forms, documents and other
attachments are you providing with this form? attachments are you providing with this form?
If you are not sure, check the question to see if you should If you are not sure, check the question to see if you should
attach the documents. attach the documents.
Where you are asked to supply documents, please attach Where you are asked to supply documents, please attach
original documents. original documents.
Proof of identity If you are claiming, proof of identity
There is a complete list of acceptable documents There is a complete list of acceptable documents
in the Information Booklet in the Information Booklet
Proof of your date of birth If you are claiming, proof of your date of birth
(see question 13) (see question 13)
Authorising a person or organisation Authorising a person or organisation
to enquire or act on your behalf form (SS313) to enquire or act on your behalf form (SS313)
(If you answered Yes at question 27) (If you answered Yes at question 27)
Proof of Australian residence status Proof of Australian residence status
(If you answered No at question 32) (If you answered No at question 32)
Dependent children proof of birth
(see question 43E)
Claim for a Health Care Card form (SS050)
(If you answered Yes at question 50)
Original Notice of Assessment issued Original Notice of Assessment issued
by the Australian Taxation Office by the Australian Taxation Office
(see question 53A) (see question 53A)
Documents verifying amount of foreign income Documents verifying amount of foreign income
you do not pay Australian income tax on you do not pay Australian income tax on
(see question 53B) (see question 53B)
Tax return Tax return
(see question 53C) (see question 53C)
Payment summary or a letter from your employer Payment summary or a letter from your employer
(see question 53D) (see question 53D)
Payment summary and/or tax return Payment summary and/or tax return
(see question 53E) (see question 53E)
Documents to support the reason your income Documents to support the reason your income
will be lower will be lower
(see question 55) (see question 55)
SA296.1403 17 of 18You Your partner
58 IMPORTANT INFORMATION IMPORTANT INFORMATION
Privacy and your personal information Privacy and your personal information
Your personal information is protected by law, including Your personal information is protected by law, including
the Privacy Act 1988, and is collected by the Australian the Privacy Act 1988, and is collected by the Australian
Government Department of Human Services for the Government Department of Human Services for the
assessment and administration of payments and assessment and administration of payments and
services. This information is required to process your services. This information is required to process your
application or claim. application or claim.
Your information may be used by the department or given Your information may be used by the department or given
to other parties for the purposes of research, to other parties for the purposes of research,
investigation or where you have agreed or it is required investigation or where you have agreed or it is required
or authorised by law. or authorised by law.
You can get more information about the way in which the You can get more information about the way in which the
Department of Human Services will manage your Department of Human Services will manage your
personal information, including our privacy policy at
www. personal information, including our privacy policy at
www.
humanservices.gov.au/privacy or by requesting a copy humanservices.gov.au/privacy or by requesting a copy
from the department. from the department.
59 Statement Statement
I declare that: I declare that:
• the information provided in this form is complete and • the information provided in this form is complete and
correct. correct.
I understand that: I understand that:
• giving false or misleading information is a serious • giving false or misleading information is a serious
offence. offence.
• I may need to give further information if requested. • I may need to give further information if requested.
• the Australian Government Department of Human • the Australian Government Department of Human
Services can make relevant enquiries to make sure I Services can make relevant enquiries to make sure I
receive the correct entitlement. receive the correct entitlement.
• I must notify the Australian Government Department of • I must notify the Australian Government Department of
Human Services of any changes to this information Human Services of any changes to this information
within 14 days of the change occurring. within 14 days of the change occurring.
Your signature Your signature
Date Date
/ / / /
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