ss313 1807en F
ss313 1807en F
ss313 1807en F
When to use this form Use this form to request a person or organisation be a:
• Person permitted to enquire, or
• Correspondence nominee, and/or
• Payment nominee.
If you or your nominee have your Centrelink payments income managed, call
1800 132 594 before filling in this form.
Important information We may review your nominee arrangement from time to time. This is to make sure you are happy
with the arrangement and that your nominee is fulfilling their responsibilities.
If you think your nominee arrangement is being misused, call 132 850 or visit one of our service
centres.
If you are affected by family and domestic violence, call 132 850 Monday to Friday, between
8.00 am and 5.00 pm, local time and ask to speak to a departmental social worker. For more
information, go to humanservices.gov.au/domesticviolence or call 000 if you are in immediate
www.
danger.
Choosing your Authorising a person or organisation to enquire, act on your behalf or receive your payment does
arrangement not prevent you from dealing with us about your Centrelink business.
There are different types of arrangements to help you with your Centrelink business. The
information below may help you choose the arrangement that best suits your needs:
• nominees can do more for you than a person who only has permission to enquire. A nominee
has more responsibilities and needs to be willing to take on the nominee role.
• you can only have one correspondence nominee and one payment nominee, however, they do
not have to be the same person or organisation.
• you can have a person permitted to enquire in addition to a nominee.
• you will need to complete a separate form if you want to have a different correspondence
nominee to your payment nominee or person permitted to enquire.
The person you appoint as a nominee cannot already have a correspondence or payment
nominee acting on their behalf.
Correspondence You can choose someone to be your correspondence nominee and/or a payment nominee.
nominee They can be a different person or organisation for each nominee type or the same for both.
A correspondence nominee is required to:
• advise us of any changes in your circumstances within 14 days (within 28 days if outside
Australia)
• respond to notices if required to do so, including reporting notifiable events and must be aware
that failure to respond to a notice means that you have failed to meet your obligations
• act in your best interest, and
• advise us of any changes that may affect their ongoing ability as a nominee.
They will receive copies of all your Centrelink letters from us, can enquire, act and make changes
to all your Centrelink payments and services on your behalf. This includes:
• asking us questions
• telling us about changes to your circumstances
• completing and signing forms and statements, and
• coming to appointments with you or, if appropriate, for you.
BOTH correspondence A BOTH correspondence and payment nominee arrangement allows your nominee to enquire,
and payment nominee act and make changes AND receive payments on your behalf.
Proof of identity Before the arrangement for an individual can be processed, the nominee or person permitted to
enquire is required to provide proof of their identity. To do this, they are required to provide photo
identification in person to one of our service centres.
Stopping or changing You can cancel or change your arrangement at any time, unless it is a court, tribunal,
your arrangement guardianship or administration appointed arrangement.
To cancel the arrangement:
• call us - go to humanservices.gov.au/phoneus
www.
• use your online account to cancel or change your correspondence and/or payment nominee
arrangements at any time
• write to us - go to humanservices.gov.au/contact
www.
When you cancel your nominee arrangement, a letter will be automatically issued to you and your
nominee advising that the arrangement has been cancelled at your request.
SS313.1807
Notes—2 of 2
Instructions
No Go to next question
3 Your date of birth Yes Give details below
/ / Other name(s)
Postcode
Your postal address (if different from above)
Postcode
CLK0SS313 1807
SS313.1807
1 of 4
10 Your requested organisation’s details 13 Please read this before you answer questions 13 to 15
Trading name of organisation For more information about the different arrangement types,
This is the name of the organisation, not the contact person. refer to the Notes.
The name of the contact person is to be provided at the end If you have a nominee arrangement of the same type already
of this question. in place, this request will automatically cancel the existing
arrangement.
Your existing nominee will receive a letter advising that the
arrangement has been cancelled at your request.
Business name of organisation
What arrangement are you requesting?
Australian Business Number (ABN) If you want to request arrangements with more than one
person or organisation, you will need to complete a separate
This is mandatory when nominating an organisation. form for each one.
@
14 Give details of the nominee’s account where your Centrelink
payments are to be paid
Name of contact person It may be easier for your nominee to manage your payments
by having a separate bank account.
Your nominee must tell us if they change this bank account.
From / / To / /
SS313.1807
2 of 4
Privacy notice You will need to provide evidence of the person’s inability
to sign if the arrangement is not court appointed.
17 You need to read this Attach a letter from the treating doctor or a copy of
the medical evidence of the customer’s incapacity or
Privacy and your personal information
inability to sign this form.
Your personal information is protected by law (including
the Privacy Act 1988) and is collected by the Australian Name of the person signing on behalf of the customer
Government Department of Human Services for the
assessment and administration of payments and services. This
information is required to process your application or claim.
Relationship to customer
Your information may be used by the department, or given
to other parties where you have agreed to that, or where it
is required or authorised by law (including for the purpose of
research or conducting investigations). Address
You can get more information about the way in which the
department will manage your personal information, including
our privacy policy, at humanservices.gov.au/privacy
www.
Postcode
18 If you have a physical or mental disability and are unable to Contact phone number
sign this form Go to 19
Click to go to 19
( )
Your declaration
I declare that the information I have provided in this form is Third party declaration
complete and correct. I declare that:
I authorise the person or organisation named on this • the information I have provided in this form is complete and
form, to deal with Centrelink on my behalf according to the correct.
arrangement shown on this form. • the customer is unable to sign this form due to physical or
mental disability.
I understand that: • it is in the customer’s best interest to authorise the person
• if my arrangement is voluntary, I can cancel it with or organisation named on this form, to deal with Centrelink
Centrelink at any time. on the customer’s behalf according to the arrangement
• giving false or misleading information is a serious offence. shown on this form.
• the arrangement may be rejected or cancelled at any
time by the Australian Government Department of Human Signature of the person signing on behalf of the customer
Services, if the person or organisation is not able to meet
their responsibilities and obligations.
On completion of this form,
please print and sign by hand
Your signature
Date
On completion of this form,
please print and sign by hand / /
Date
20 Which of the following documents are you providing with this
/ / Go to 20 form?
Where you are asked to supply documents, attach copies only.
The copies will not be returned.
19 Third party authorisation
If the customer is unable to sign this form due to physical
or mental disability and the nominee arrangement is in the Tick ALL that apply
person’s best interest, a third party may sign this section on Original photo identification – your nominee or person
their behalf. permitted to enquire is required to take it in person to
For example, an appropriate third party may be: one of our service centres
• a professional like a treating doctor, nurse, case worker or
social worker, or Copy of the legal document
(if required for question 15)
• the Enduring Power of Attorney if it has been made, or
• the person or organisation appointed by a guardianship A letter from the treating doctor or a copy of the medical
board, court or tribunal as the customer’s guardian or evidence of the customer’s incapacity or inability to sign
administrator. this form
(if required for question 19)
SS313.1807
3 of 4
Part B – To be completed by your NOMINEE or PERSON Returning your form
PERMITTED TO ENQUIRE
You can return this form and any supporting documents:
• online (excluding identity documents) using your Centrelink
21 Provide a password online account. For more information, go to www.
We will ask this password every time you contact us. humanservices.gov.au/submitdocumentsonline
The password needs to have 4 to 12 letters or numbers. • in person at one of our service centres, if you are unable to use
your Centrelink online account.
If you are outside Australia, you can:
• post to: Department of Human Services
Privacy notice International Services
PO Box 7809
22 You need to read this CANBERRA BC ACT 2610
Australia
Privacy and your personal information • fax to: +61 3 6222 2799
Your personal information is protected by law (including
the Privacy Act 1988) and is collected by the Australian
Government Department of Human Services for the
assessment and administration of payments and services. This
information is required to process your application or claim.
Your information may be used by the department, or given
to other parties where you have agreed to that, or where it
is required or authorised by law (including for the purpose of
research or conducting investigations).
You can get more information about the way in which the
department will manage your personal information, including
our privacy policy, at humanservices.gov.au/privacy
www.
Date
/ /
Print Clear
SS313.1807
4 of 4