Application For Housing Assistance Form Page 15
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19Person 4
Title
Mr, Mrs, Ms, Miss
See item 1 on the Evidence
Requirements Information
Last name
Sheet for details.
or family name
First and middle name(s)
Is this person known by another name?
Yes
No
give details
(for example, previous family name)
What name?
Family Name
First Name
Relationship to you
Centrelink Reference Number
(if applicable)
Sex
Male
Female
Date of birth
DD/MM/YYYY
Does this person have a different residential
Yes
No
address from you?
address of person
Phone
Mobile
Email
Is this person of Aboriginal or Torres
Yes
No
Strait Islander descent?
give details
Aboriginal
See item 3 on the Evidence Requirements
Torres Strait
Aboriginal
Information Sheet for details.
and Torres
Islander
Strait Islander
Australian
Permanent
Sponsored
What is this person’s current
citizen
resident
migrant
citizenship or residency status?
See items 4 and 5 on the Evidence
New Zealand
Refugee/
Asylum
Requirements Information Sheet
Special Category
humanitarian
seeker
for details.
Visa
Visa subclass number
(if not relevant, write ‘not applicable’)
Date of arrival in Australia (if applicable)
DD/MM/YYYY
PLEASE NOTE
If there are more than four additional people on your application, ask for a copy of the Additional Person Information form or download
it from
DH3001 04/15
Page 13 of 16
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