Life Certificate

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AUS061.1402
Customer’s responsibilities
You are required to have this certificate verified (see page 3) by one of the people listed below:
- notary public/advocate
- Justice of the Peace
- Australian official at an embassy,
consulate or high commission
- local social security authority
- priest or religious leader
- magistrate
- solicitor
- physician.
official papers or documents which include a photograph of yourself must be presented
as identification. Suitable documents include:
- passport
- identification card
- other official government documents.
any costs involved in getting this certificate verified will be your responsibility.
if you fail to return this certificate within 6 weeks your pension may be stopped.
1 Your personal details
Family name
First given name
Date of birth
Centrelink Reference Number
Never married or lived with a partner
Married
Partnered
(living together in an opposite-sex or
same-sex relationship, including de facto)
Widowed
(previously partnered with an opposite-sex
or same-sex partner, including in a marriage,
registered or de facto relationship)
Date of marriage
Date you started living
together as a couple
Date of partner’s death
Life Certificate
Date of decree absolute
Date of separation
Divorced
Separated
(previously lived with an opposite-sex or
same-sex partner, including in a marriage,
registered or de facto relationship)
Sex Male Female
Registered relationship
(opposite-sex or same-sex relationship
registered under Australian state or territory law)
Date of registration
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3 Do you live in the same home as
your former partner?
No
Yes
To be completed by customer
Second given name
Title Mr Mrs Miss Ms Other
2 What is your CURRENT
relationship status?
We recognise both opposite-sex
and same-sex relationships. This
includes de facto relationships
and relationships registered under
Australian state or territory law. If
you and your same-sex partner
have married or had your
relationship registered outside
Australia, please indicate your
relationship as ‘partnered’ in this
list.
Select ONE option below that best
describes your current relationship
status.
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CLK0AUS061 1402
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