Locked Bag 7834 Canberra Bc, ACT 2610

Date of Issue
11 July 2016
Your Reference Number

CLK2SS054 J246403363002

305 269 740J

Post this form to:
PO Box 7800
Canberra Bc ACT 2610

Mr Alvin A Ng
3a Five Crown Gr
DONCASTER EAST VIC 3109

SS054.1412(Page 1 of 6 )

Renewing your
Health Care Card
Purpose of this form
The information asked for on this form will be used to decide if you are still eligible for a Health Care Card.
You can renew your Health Care Card online. Go to our websitehumanservices.gov.au/centrelink and select Customer online accounts.

Returning your form

Check that all required questions are answered and that the form is signed and dated.
If you are returning this form and any supporting documents, you need to do thiswithin 21 days so we can process your application or
claim. If you cannot do this within 21 days, contact us for extra time. If extra time is required, you must contact us at the earliest possible
date to make an arrangement.
You can return this form and/or any supporting documents:

online - submit your documents online. For more information about how to lodge documents online, go to
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.

Income limit
You will get a new Health Care Card if your (and your partners) income in the 8 weeks ending on
11 JULY 2016 is less than $ 4288.00.
Note: Your income limit may change if your personal circumstances have changed, for example, if you have become partnered
(married, registered partner or de facto of the opposite-sex or same-sex) since lodging your last claim.

If you do not complete this form and send it back you will not get a new Health Care Card.

If you are partnered, your partner must also answer the questions and sign the form.

1/1-1

Renewing your Health Care Card SS054.1412

(Page 2 of 6 )

Personal Details
1

Has your address changed from the above address?

No

Yes

What is your new address?

Postcode

Are you partnered?

No

Yes

Partners full name?

Do you have any dependent children?

No

Yes

Have the details you previously provided to the Australian Government Department
of Human Services about your dependent child(ren) changed in the last 8 weeks?
No

Full name

Please provide details below.

If there is not enough space, please attach a separate list.
Your dependent child

A full-time student

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Are you or your children receiving an income tested Australian Government payment (other than Family Tax Benefit) or
have you claimed such a payment (eg. Youth Allowance, ABSTUDY, or a Service Pension)?
No

Yes

Yes

Name

Type of payment

Are you enrolled in, or do you intend to enrol in a course of secondary studies?
A secondary course is a course of study approved by the Department of Education. This usually means you are doing the equivalent of
full time year 10, 11 or 12 studies.
No

Yes

If yes, you will need to complete and attach a Study details form (Mod St)
if you have not already provided this to us. If you do not have this form, go to our website
humanservices.gov.au/forms

Income details
6

Self-employed

YOU

Are you (or your partner) self-employed

(such as a primary producer, sub-contractor,
or in your own business)?

No
Yes
No
Yes
If Yes, state net income from self-employment for the last
financial year.

If Yes, you must provide:

last available tax notice of assessment

last available tax return

evidence of current income from your business.

Net income means the amount left after business deductions

allowed under social security law, but before tax. Net income
must include amounts you paid into a personal
superannuation fund for which you can claim a tax deduction
on your individual tax return.
$

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YOUR PARTNER

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Income details continued

7

Renewing your Health Care Card SS054.1412

(Page 3 of 6 )

Earned or received income

YOU

Did you (or your partner) earn or receive an income

from ANY source during the past 8 weeks?

No

Do NOT include any Parental Leave Pay, Dad and Partner

Pay or funding from the National Disability Insurance Scheme.

If Yes, state source of income (e.g. employer name, compensation,

income from boarders or lodgers, annuities or regular gifts or
payments from government departments other than
the Department of Human Services).

If Yes, you must provide:

payslips for the last 8 weeks (if you received an amount for
Parental Leave Pay and your employer does not show these
amounts separately on your payslips you must write Includes
Parental Leave Pay clearly on your payslips), or

a letter from your employer stating gross wages for

the last 8 weeks (including voluntary superannuation
contributions such as amounts salary sacrificed to a super
fund but NOT including Parental Leave Pay amounts), or

if compensation, annuities or regular gifts - papers

which show who pays it and how much.
Note: Letters and payslips must have your employers
name and address on them.

YOUR PARTNER
Yes

No

Yes

Gross amount received for the last 8 weeks

$

If you receive income from more than 1 source, please

attach a separate list.
Note: The last 8 weeks referred to above is the 8
week period ending on the date printed under the
heading Income limit located at the start of this form.
8

Do you (or your partner) receive any fringe benefits

provided by an employer (e.g. use of a car as part of
a salary package, rent/mortgage paid)?
Fringe benefits means a benefit received as part
of earned income but not as a wage or salary.

YOU
No

YOUR PARTNER
Yes

No

Yes

If Yes, attach details that indicate the type of fringe benefit

and its value, and whether or not the amount is grossed-up
or not grossed up

Savings accounts
Give details below of all accounts held by you (and/or
your partner) in banks, building societies or credit unions.

Attach proof of all account balances

(e.g. ATM slip, statements, passbooks).

Include savings accounts, cheque accounts, term

deposits, joint accounts, accounts you hold in trust or
under any other name, or money held in church or
charitable development funds.
Accounts and term deposits outside Australia should be
included, with the current balance in the type of currency
in which it is invested. We will convert this into
Australian dollars.
Do NOT include shares, managed investments or an account
used exclusively for funding from the National Disability
Insurance Scheme.
Name of bank, building Account number
society or credit union (this may not be
your card number)

Type of account Balance of

account

10 Shares

Currency if not
AUD

Partners
share

YOU

Do you (and/or your partner) own any shares, options,

rights, convertible notes or other securities LISTED on
an Australian Stock Exchange
(e.g. ASX, NSX, APX or Chi-X) or a stock exchange outside
Australia?

Your
share

YOUR PARTNER

No
Yes
No
Yes
If Yes, give details below
Attach the latest statement for each share holding.

Include shares traded in exempt stock markets.

Do NOT include managed investments.
Name of company

Number of shares ASX code (if known) Country if not

or other securities
Australia

Your
share

Partners
share

%
%

2/1-1

%
%

Income details continued

Renewing your Health Care Card SS054.1412

11 Do you (and/or your partner) own any shares, options

or rights in PUBLIC companies, NOT listed on a stock
exchange?
Do NOT include managed investments.

(Page 4 of 6 )

YOU

YOUR PARTNER

No
Yes
If Yes, give details below

No

Yes

Attach the latest statement detailing your share holding for

each company (if available).
Name of company

Type of shares

Number of shares

12 Managed investments

Current market
value

YOU

YOUR PARTNER

No

Include:

investment trusts

personal investment plans

life insurance bonds

friendly society bonds.

Do NOT include:

conventional life insurance policies

funeral bonds, superannuation or rollover investments.

APIR code is commonly used by fund managers to
identify individual financial products.

If Yes, give details below

Name of product
(e.g. investment
trust)

Partners
share

Do you (and/or your partner) have any managed

investments in and/or outside Australia?

Name of company

Your
share

Yes

No

Yes

Attach a document which gives details (e.g. certificate with

number of units or account balance) for each investment.

Type of product/
Number
option (e.g.
of units
balanced, growth)

APIR code
(if known)

Current Market Currency Your

value
if not AUD share

Partners
share

13 Superannuation YOU should answer this question ONLY if you are over age pension age or claiming Age Pension. YOUR
PARTNER should answer this question ONLY if they are over age pension age or claiming Age Pension.
The qualifying age for Age Pension is currently 65 years.
From 1 July 2017, the qualifying age for Age pension will increase from 65 years to 65 years and 6 months. The
qualifying age will then rise by 6 months every 2 years, reaching 67 years by 1 July 2023. See table below.
Date of Birth
1 July 1952 to 31 December 1953
1 January 1954 to 30 June 1955
1 July 1955 to 31 December 1956
From 1 January 1957

Qualifying age at
65 years and 6 months
66 years
66 years and 6 months
67 years

Do you (or your partner) have any money invested in

superannuation where the fund is still in accumulation
phase and not paying a pension?

YOU

Include:

superannuation funds such as retail, industry, corporate

or employer and public sector

retirement savings accounts

Self Managed Superannuation Funds (SMSF) and Small

APRA Funds (SAF) if the funds are complying.

If Yes, give details below

Attach the latest statement for each superannuation investment.
If you are a SMSF or SAF, attach the financial returns and member
statement for the fund.

Name of institution/fund manager

Name of fund

No

Date of
joining/investment

YOUR PARTNER
Yes

Yes

Current market Owned by

value
$

160713 BCH - 104801

No

You

Your partner

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Income details continued

Renewing your Health Care Card SS054.1412

14 Trusts

YOU

Are you or have you (and/or your partner) been involved

in a private trust in any of the ways detailed below?
You (and/or your partner) may be, or have been involved
in a trust as:

a trustee

an appointor

a beneficiary
OR have:

made a loan to a private trust

made a gift of cash, assets, or private property to a private

trust in the last 5 years

relinquished control of a private trust in the last 5 years

a private annuity

a life interest

an interest in a deceased estate.

A private trust includes a non-complying Self Managed
Superannuation Fund or a non-complying Small APRA Fund.
15 Companies

No

(Page 5 of 6 )

YOUR PARTNER
Yes

No

Yes

If Yes, you (and/or your partner) will need to complete and

attach a Private Trust form (Mod PT) if you have not already
provided this to us. If you do not have this form, go to our
website humanservices.gov.au/forms

YOU

YOUR PARTNER

Are you or have you (and/or your partner) been involved

in a private company in any of the ways detailed below?

No

You (or your partner) may be, or have been in the last 5
years:

a director of a company

a shareholder of a company
OR have:

made a loan to a private company

transferred shares in a private company

made a gift of cash, assets or property to a private company.

If Yes, you (and/or your partner) will need to

complete and attach a Private Company form (Mod
PC) if you have not already provided this to us. If you
do not have this form, go to our website
humanservices.gov.au/forms

16 Lump sum payments

In the last 12 months, have you (or your partner)
received a lump sum payment that you have not
already advised on this form?
Do NOT include:

compensation, insurance or damages lump sum payments

funding from the National Disability Insurance Scheme.

Type of lump sum

Who paid it?

Yes

No

YOU

YOUR PARTNER

No
Yes
If Yes, give details below

No

Amount paid

Date paid

Yes

Who received this lump sum

payment?

$
17 Compensation, insurance and/or damages

Yes

You

YOU

Your partner

YOUR PARTNER

Since you last claimed or renewed your Low Income

Health Care Card have you (or your partner) CLAIMED
or are you ABLE TO CLAIM compensation, insurance
and/or damages?

No

Include:

workers compensation/damages as a result of a work injury

third party damages as a result of a motor vehicle accident

personal accident and sickness insurance or income

replacement/protection insurance

sporting injury compensation

public liability compensation

medical negligence compensation

damages paid to victims of crime or as a result of criminal

injuries.

If Yes, you (and/or your partner) will need to complete and

attach a Compensation and damages form (Mod C) if you
have not already provided this to us. If you do not have this
form, go to our website humanservices.gov.au/forms

3/1-1

Yes

No

Yes

Income details continued

Renewing your Health Care Card SS054.1412

18 Gifts

YOU

In the last 5 years, have you (or your partner) given

away, sold for less than their value, or surrendered
a right to, any cash, assets, property or income?

No

(Page 6 of 6 )

YOUR PARTNER
Yes

No

Yes

If Yes, give details below

Include forgiven loans and shares in private companies.

Note: If you give away assets or sell them for less than their
value your claim for a Health Care Card could be affected.
What you gave away or sold for less
than its market value (e.g. money,
car, second home, land, farm)

Date given
or sold

What it
was worth

What you
got for it

Your
share

19 Other income

Partners
share

YOU

Do you (or your partner) receive income from

property or other assets not already mentioned
above (e.g. rent payments)?
Do NOT include funding from the National Disability
Insurance Scheme.

Was this gift to a

Special Disability
Trust (SDT)?

No

Yes

YOUR PARTNER

No
Yes
No
Yes
If Yes, you must provide a copy of last available tax return
or other papers which show income and mortgage details.
If Yes, state annual income

$
20 Income streams

YOU

YOUR PARTNER

Do you (and/or your partner) receive income from any

income stream products?

No
Yes
If Yes, give details below

No

An income stream product is a regular series of

payments which may be made for a lifetime or a fixed
period by:

a financial institution

a retirement savings account

a superannuation fund

a Self Managed Superannuation Fund (SMSF)

a Small APRA Fund (SAF)

You (and/or your partner) will need to attach a

Details of income stream product form (SA330) or a
similar schedule, for each income stream product.
The form or similar schedule must be completed by your
product provider or the trustee of the Self Managed
Superannuation Fund (SMSF) or Small APRA Fund (SAF)
or the SMSF administrator.

Yes

If you do not have this form, go to our website

Types of income streams include:
humanservices.gov.au/forms

account-based pension (also known as allocated pension)

market linked pension (also known as term allocated

pension)

annuities

defined benefit pension (e.g. CompSuper pension, State

Super pension)

superannuation pension (non-defined benefit).

Name of product
Type of income stream
Product reference
Commencement
Your
provider/SMSF/SAF
number
date
share

Partners
share

%
21 Permission to enquire

YOU

Do you give permission for your

partner to discuss your Health Care
Card with us?
You can change this authority at any time.

No

YOUR PARTNER
Yes

No

Yes

22 IMPORTANT INFORMATION
Privacy and your personal information
Your personal information is protected by law, including thePrivacy 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 for the purposes of research, investigation or where you have
agreed or it is required or authorised by law.
You can get more information about the way in which the Department of Human Services will manage your personal information, including
our privacy policy at humanservices.gov.au/privacy or by requesting a copy from the department.

Statement
I declare that
I understand that

the information I have provided in this form is complete and correct.

giving false or misleading information is a serious offence.

Your signature

Your partners signature (if applicable)

Date

Date

160713 BCH - 104801

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