Aged Care Fees Income Assessment Request - Australian Department Of Human Services Page 10
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26Help with your form
If you want information about how to answer the questions in this form, and:
• you receive a Centrelink income support payment, or
• you are a self-funded retiree,
call the Department of Human Services.
If you want information about how to answer the questions in this form, and:
• you receive a Department of Veterans’ Affairs income support payment,
call the Department of Veterans’ Affairs on 133 254, if you live in regional Australia call on
Freecall™ 1800 555 254.
For general information on fees and charges applying to aged care, go to My Aged Care website
myagedcare.gov.au or call us on Freecall™ 1800 200 422.
If you need specific advice on completing this form or on applying for financial hardship
assistance, go to humanservices.gov.au/agedcare or call us on Freecall™ 1800 227 475.
This form is not an application for Financial Hardship Assistance. For information about Financial
Hardship Assistance, go to humanservices.gov.au/agedcare or call us on Freecall™ 1800 227 475.
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
Check that you have answered all the questions you need to answer and that you have signed
and dated this form.
• if you receive an income support payment from Centrelink, return your form and any additional
documents to:
Department of Human Services
Residential Care
Reply paid 7821
Canberra BC ACT 2610
• if you receive an income support payment from the Department of Veterans’ Affairs, return
your form and any additional documents to:
Department of Veterans’ Affairs
Aged Care Assets Assessments
GPO Box 9998
In your capital city
Note: ACT residents should post their form to Sydney
NT residents should post their form to Adelaide
• if you do NOT receive an income support payment from either Centrelink or the
Department of Veterans’ Affairs, return your form to the Department of Human Services
(address above).
You should lodge this form before you commence care (if possible) to make sure that your income
for aged care fees purposes can be calculated as quickly as possible. If you commence your care
without having an income assessment, you could be asked to pay the maximum aged care fees
applicable.
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SA456.1705
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