Mobility Allowance Claim for Advance Payment - Australia
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MA007T.1403
Your name
Other
Family name
1
First given name
Second given name
MsMissMrsMr
Your permanent address
Postcode
2
Your postal address (if different to above)
3
4
Postcode
Your contact details
Home phone number
Is this a silent number?
Mobile phone number
( )
No Yes
Paid work
Training course
Voluntary work
Life Skills training (e.g. managing money)
Looking for work
Your Centrelink Reference Number (if known)
5
Which of the following are you doing:
Tick more than one if applicable
7
Vocational rehabilitation activities
No
Yes
Details of the organisation(s) you are doing the above
activities with.
8
Name of organisation
Address
Postcode
Phone number
What type of activity are you doing with this organisation
(e.g. work, training)?
How many hours per week are you doing this?
hours per week
Are these hours the same each week?
Go to 11
Go to next question
How many hours do you spend over a 2 week period doing
the above activities?
9
How many hours do you spend over a 4 week period doing
the above activities?
10
hours
hours
( )
Are you receiving a funded package of support from the
National Disability Insurance Scheme?
6
No
You cannot receive an advance payment of
Mobility Allowance. For more information
call us on 132 717.
You will need to sign the statement at
question 18 and return this form to us.
Yes
Go to next question
Go to 17
If you are not sure you can call the National Disability
Insurance Agency on 1800 800 110.
CLK0MA007T 1403
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