Secondary Assistance Scheme Application Form - Department Of Education

2017 SECONDARY ASSISTANCE SCHEME

YEARS 7 - 12

$115 Clothing Allowance Paid to parent (or) school

$235 Education Program Allowance Paid to school



Valid to claim with Parent/Guardian card only.



Student cannot claim with own card if living with parent(s).

APPLICATIONS CLOSE



Not eligible if student born in 1998 or before.

FRIDAY 7 APRIL 2017



If living as an independent student, letter of proof from Centrelink must be provided.



Please complete form neatly and in block letters and retain a copy at the school.



SCHOOL NAME

SCHOOL CODE

(Please use school stamp including phone number if possible)

PARENT/GUARDIAN DETAILS

SURNAME

FIRST NAME

STREET

SUBURB

POSTCODE

CONTACT PHONE No.

E-MAIL

PARENT/GUARDIAN DEPARTMENT OF HUMAN SERVICES (CENTRELINK) CONCESSION CARD DETAILS

Veterans’ Affairs Pensioner Card

Centrelink Health Care Card

Centrelink

(Blue card only – expires Dec 2017)

(Family Card only NOT Student card)

Pensioner Concession Card

CARD No. (CRN OF PARENT/GUARDIAN):

(as per Centrelink Card)

CARD

START DATE ON

EXPIRY Date:

CARD:

(must fall on or after first day of

Term One)

STUDENT DETAILS

INDEPENDENT STUDENT

(Attach letter from Centrelink)

YEAR

CLOTHING ALLOWANCE TO

SURNAME

FIRST NAME

DATE OF BIRTH

LEVEL

BE PAID TO (tick)

SCHOOL

PARENT

SCHOOL

PARENT

SCHOOL

PARENT

BANK ACCOUNT DETAILS OF PARENT/GUARDIAN (Complete only if clothing allowance to be paid to parent)

Payments will only be made by EFT – Please write clearly

Name of Account Holder(s):

BSB Number: (6 digits)

Account Number: (up to 9 digits)

PARENT/GUARDIAN DECLARATION



I have not claimed nor do I intend to claim the ABSTUDY School Fees Allowance in 2017.



I have not claimed this allowance for any of these children at another school in Western Australia in 2017.



I authorise the Department of Human Services (Centrelink) to verify my current benefit status and other pertinent details

to gain this entitlement.

I DECLARE THE ABOVE TO BE TRUE AND CORRECT AND AM AWARE THAT IT IS AN OFFENCE TO PROVIDE FALSE

OR MISLEADING INFORMATION.

PARENT/GUARDIAN SIGNATURE:

DATE:

____________________________________

__________________

WITNESS DECLARATION

(Concession card must be sighted and witnessed at attending school)

I have sighted the claimant’s card and confirm the details provided are correct.

PRINT NAME OF WITNESS

WITNESS SIGNATURE

POSITION HELD

DATE

If the form is completed and dated prior to the start of Term 1 complete the commencement confirmation below

(tick box and enter current date).

□

I confirm that the above student(s) has/have commenced at this school in Term 1, 2017

DATE:____________________

Secondary Assistance Scheme Application Form - Department Of Education - 2017 Page 2

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