Claim for Age Pension and Pension Bonus
SA002.1503
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Your date of birth
/ /
7
Your permanent address
Postcode
8
Your sex
6
Male
Female
Your postal address (if different to above)
9
Postcode
Attach an original document as proof of your date
of birth.
If you are claiming Age Pension, attach an original
document as proof of your date of birth.
Your sex
Male
Female
/ /
Your date of birth
You Your partner
Your permanent address
Postcode
Your postal address (if different to above)
Postcode
7
8
6
9
10
Your contact details Your contact details
Home phone number
Is this a silent number?
Email
@
Fax number
Work phone number
Alternative phone number
( )
( )
( )
( )
No Yes
Mobile phone number
Home phone number
Is this a silent number?
Email
@
Fax number
Work phone number
Alternative phone number
( )
( )
( )
( )
No Yes
Mobile phone number
10
If you provide an email address or mobile phone number,
you may receive electronic messages (SMS or email)
from us. To read the Terms and Conditions, go to
www.humanservices.gov.au/em or visit one of our service
centres.
Please read this before answering the following question.
If you provide an email address or mobile phone number,
you may receive electronic messages (SMS or email)
from us. To read the Terms and Conditions, go to
www.humanservices.gov.au/em or visit one of our service
centres.
Please read this before answering the following question.
Page 4/25
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