Income and Assets Sample Form
SA369.1409
Income and Assets
1 of 17
This form asks you to provide information about your income and assets.
This information is used to calculate your Centrelink payment.
Purpose of this form
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
(and your partner) have signed and dated this form.
You can return this form and any supporting documents:
• online – submit your documents online. For more information about how to access an
Online Account or how to lodge documents online, go to
www.
humanservices.gov.au/submitdocumentsonline
• by post
• in person – if you are unable to submit this form and any supporting documents online
or by post, you can provide them in person to one of our Service Centres.
For more information
Go to our websitewww.humanservices.gov.au/dsp orwww.humanservices.gov.au/carerpayment
or
www.humanservices.gov.au/agepension or call us on 132 717 for Disability, Sickness and
Carers or 132 300 for Seniors or visit one of our Service Centres.
If you need a translation of any documents for our business, we can arrange this for you
free of charge.
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 or speech impairment you can contact the TTY service on
Freecall™ 1800 810 586. A TTY phone is required to use this service.
Online Services
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
You must tell us about your partner’s income and assets.
You can complete this form for both you and your partner.
OR
You may choose to complete an
Income and Assets
form (SA369) separately.
If you choose this option, tick this box
If you need more copies of this form, go to our website
www.humanservices.gov.au/forms
If you have a partner
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Income and Assets Sample Form PDF
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