Instructions

Notes for
Private Company
This form is used to work out your share of a private
company’s income and assets.

When to use this form Use this form if in the last 5 years you (and/or your partner):
• have been involved with or transferred any shares related to a private company that is still
registered through the Australian Securities Investment Commission (ASIC)
• have been involved with a private company registered overseas
• have made any type of gifts involving a private company (either registered or deregistered).
You do not need to complete this form if:
• the private company is now deregistered with ASIC and no gifts need to be declared.

Online services You can upload this form, with any supporting documents, online.
For more information about how to access an online account or how to lodge documents online,
go to servicesaustralia.gov.au/submitdocumentsonline
www.

Using a tax agent or Much of the information required on the form is only available from those who know the details of
accountant the company. Services Australia is not able to help you complete the form.
We suggest you talk to the company tax agent or accountant and consider having them complete
the form on your behalf. It is still your responsibility to make sure the form is completed and returned.
If a tax agent or accountant provides information, advice or completes the form, or provides the
Income Tax Returns for the company, we will not reimburse any fees they may charge you for this
service.

What else you will If you are making a claim, you must return this form and all other supporting documents at the
need to provide same time you lodge your claim form. If you do not return all documents, your claim may not be
accepted. The only exception will be if you are waiting for medical evidence or other documents
from a third party.

For more information Go to servicesaustralia.gov.au/trustsandcompanies or visit one of our service centres.

www.

If you need to call us, go to servicesaustralia.gov.au/phoneus

www.

We can translate documents you need for your claim for free.
To speak to us in your language call 131 202.
Call charges may apply.
If you have a hearing or speech impairment, you can contact the TTY service Freecall™
1800 810 586. A TTY phone is required to use this service.

Keep these Notes (pages 1 to 4) for your information.

Mod(PC).2005
Notes—1 of 4
Definitions What is a private company?
For social security purposes, a private company is a company that meets the following rules:
• The company satisfies at least 2 of the following conditions:
–– the consolidated gross operating revenue for the financial year for the company and its
subsidiaries is less than $50 million
–– the value of the consolidated gross assets at the end of the financial year of the company
and its subsidiaries is less than $25 million
–– the company and its subsidiaries have fewer than 100 employees at the end of the financial
year, or
• the company is a new company and came into existence after the end of the last financial
year, or
• the company is a declared private company, and
• the company is not an excluded company.

Involvement in a private company

A person is involved in a private company if they or their partner:
• are a shareholder, director or other office holder of the company
• are owed money by the company
• have provided, for less than market value, property or services to the company since 9 May 2000
• can expect the director, governing director or major shareholder of the company to act in
accordance with their wishes
• are able to benefit from the company.
A direct benefit
A person may enjoy a direct benefit from a company by having the company pay all their personal
living expenses or using the company assets as if they were their own personal assets.
An indirect benefit
A person may enjoy an indirect benefit from the company by having access to and use of company
assets such as holiday homes.

Assessment of private company income and assets

Attribution
If we attribute any share of the income or assets of a company to you, this means we treat them
as yours.
To decide this, we use either:
• a control test
• a source test.
The control test
Control of a company rests with those persons who hold majority voting powers or governing
director type powers.
A person may also control a company by being able to influence the major shareholder or director
to act in their favour. In some cases, the major shareholder or director could be expected to act
in accordance with their wishes. A person may also be considered to control a company through
their use and enjoyment of the income and assets.
The source test
The source test only applies where a person transfers assets or services to a company after
7:30 pm Australian Eastern Standard Time (AEST) 9 May 2000.

Mod(PC).2005
Notes—2 of 4
 The Source Test recognises that if you and/or your partner transfer assets or services to a company
and do not receive adequate consideration in return, you generally retain some means of control.
Where you can clearly show that a genuine gift has been made and you have no ongoing
involvement in the company at all, attribution would not be made.
Resignations
If you relinquish control of a private company, you will be considered to have gifted the assets
held by the company.
Gifts may be assessed for 5 years from the date of transfer.
Note: Documentation may be requested.

Associates
Associates include:
• directors
• shareholders
• spouse/partner
• a business partner
• parents and grandparents
• children (whether biological, adoptive, step or foster) and their spouse/partner and the children
of those parties and the spouse/partner of those children
• siblings and their spouse/partner
• nephews and nieces and their spouse/partner and the children of those parties and the
spouse/partner of those children
• uncles, aunts and their spouse/partner and the children of those parties and the
spouse/partner of those children
• a professional adviser such as an accountant, solicitor or financial adviser who may be
expected to act in accordance with a person’s wishes
• a trustee of a trust from which a person is capable of benefiting under the trust directly or
indirectly
• a company where the directors could reasonably be expected to act in accordance with a
person’s directions or wishes, or where a person and associates are able to cast more than
50% of the votes that may be cast at a general meeting of the company.

Authority to inspect Purpose of this authority

the property To enable us to correctly assess your entitlement, it may be necessary for a valuation of a property
held by the company to be completed.
In order to continue paying your correct entitlement, we may arrange to have the property
professionally valued from time to time, at no cost to you.

Information about having a valuation

Why is a valuation required?
Social security law requires that the value of assets (for example, property, shares in a company,
units in a trust) is included when calculating the amount of pension, benefit or allowance payable.
How is the value of a property decided?
The value of real estate is its current market value, less any allowable debts on the property.
The ‘current market value’ is the price the owner could expect to receive if the property was sold.
Through regular updates using relevant market data, we will maintain the value of the property.

Continued
Mod(PC).2005
Notes—3 of 4
 What happens if there is no permission to inspect the property?
If the value of the property is likely to affect a person’s entitlement to social security payments or
the rate of payment, but no permission to inspect the property is provided, the person’s payment
may not be granted, payment may be reduced or payment may be stopped.

Mod(PC).2005
Notes—4 of 4
 Instructions

Private Company

5 Your partner’s name

Filling in this form
Family name
You can complete this form on your computer, print and
sign it.
If you have a printed form: First given name
• Use black or blue pen.
• Print in BLOCK LETTERS.
Second given name
• Where you see a box like this Go to 1 skip to
the question number shown.
• Use a separate form for each company.
• If you need more space to answer any questions, 6 Your partner’s date of birth
provide a separate sheet. Write the company name / /
and your Centrelink Reference Number (CRN)
if known, on each sheet.
• Each form can be used jointly for all our customers 7 Is your only role in the private company as a director and
and their partners who are involved in the company. you have no shares in, or loans to the company?
For privacy, you may choose to complete your own No Go to 10
separate form.
Yes Go to next question

8 Have you (and/or your partner) ever held shares in the

About you company?
No Go to next question
1 Your Centrelink Reference Number (if known) Yes Go to 10

9 Have you (and/or your partner) gifted, transferred or sold

assets to this company for less than their market value
2 Your name or provided services to the company and not received
Family name adequate payment/consideration since 7:30 pm AEST
on 9 May 2000?

First given name No You will need to provide details of your

wages from this company. Refer towww.

servicesaustralia.gov.au/incomereporting
Second given name Go to 75

Yes Go to next question

3 Your date of birth

/ /

4 Do you have a partner?

For the definition of a partner, go to www.

servicesaustralia.gov.au/moc

No Go to 7
Yes Go to next question

CLK0Mod(PC) 2005

Mod(PC).2005
1 of 20
 About the private company 13 Provide contact person details for future requests for
taxation returns and financial statements of the company,
if required for a review (for example, you, your tax agent
10 What is the name of the private company? or accountant).
This private company will be referred to as ‘the company’ The person named at question 12 Go to next question
on the rest of this form.
The person named below Give details below
Name

Business name (if applicable)

11 Company tax file number (Company TFN)
Position in relation to the company discussed in this form
Company Australian Business Number (Company ABN)
Postal address

Company Australian Company Number (Company ACN)

Postcode
12 Provide details of the person we can contact about details Daytime phone number
given in this form (for example, you, your tax agent or
accountant). Fax number ( )
Name
14 In which month are the taxation returns and financial
Business name (if applicable) statements for the company normally completed?

Position in relation to the company discussed in this form

15 Is this company a corporate trustee only that does not
trade in its own right?
Postal address No Go to next question
Yes Give details below
Name of the trust
Postcode

Daytime phone number You will need to complete and return a

Private Trust (Mod PT) form for the trust.
Fax number ( ) If you do not have this form, go to
www.

servicesaustralia.gov.au/forms

16 When was the company incorporated?

/ /

What date did the company commence trading?

/ /

17 Is the company still trading?

No Go to next question
Yes Go to 20

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18 What date did the company cease trading? 21 Read this before answering the following question.
/ / Only answer questions 22 and 23 if you (and/or your
partner) are age pension age or claiming Age Pension
otherwise, Go to 24
19 Explain why the company ceased trading
To work out if you (or your partner) are Age Pension
age, use the table below.
Date of birth Qualifying age at
1 July 1952 to 31 December 1953 65 years and 6 months
1 January 1954 to 30 June 1955 66 years
1 July 1955 to 31 December 1956 66 years and 6 months
From 1 January 1957 67 years

From 1 July 2019, the Work Bonus will also apply to

20 Trading name(s) under which the company conducts self-employment income of Age Pension age customers
business and the type of business if the income earned is a direct result of your actions or
effort in a particular task.
1 Trading name
This means if you work for financial gain or reward,
that involves your personal exertion, you will be eligible
Type of business (for example, primary production, to have the Work Bonus applied to that income.
retail, commercial, investment) For example, book keeping, lawn mowing and/or other
tasks where your direct involvement generates that
income. We call this active self-employment.
2 Trading name
22 Does your (and/or your partner’s) role in the business
involve personal exertion?
Type of business (for example, primary production, This does not include domestic or household
retail, commercial, investment) maintenance tasks and management or administration
of your place of residence or any financial investment
or real property belonging to:
3 Trading name • a member of your family group
• a company that is a family company
• a trustee or trustees of a family trust.
Type of business (for example, primary production,
retail, commercial, investment) No Go to 24
Yes Go to next question

If there are more than 3 trading names, provide a 23 What percentage of the income is from personal exertion?
separate sheet with details.
1 Trading name of business

You Your partner

% %

2 Trading name of business

You Your partner

% %

3 Trading name of business

You Your partner

% %

If you need more space, provide a separate sheet with

details.
Mod(PC).2005
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24 Details of directors Company financials
1 Name
25 Total number of shares issued by the company
Date of birth 1 Class (for example,
/ / Ordinary, Class A, Class B) Number

Centrelink Reference Number (CRN) (if known)

Tick all that apply
Voting rights provided
Permanent address
Entitlement to dividends
Entitlement to capital distributions on wind up

2 Class (for example,

Postcode Ordinary, Class A, Class B) Number

2 Name
Tick all that apply
Voting rights provided
Date of birth Entitlement to dividends
/ / Entitlement to capital distributions on wind up
Centrelink Reference Number (CRN) (if known) 3 Class (for example,
Ordinary, Class A, Class B) Number
Permanent address
Tick all that apply
Voting rights provided
Entitlement to dividends
Postcode Entitlement to capital distributions on wind up
3 Name 4 Class (for example,
Ordinary, Class A, Class B) Number

Date of birth
/ / Tick all that apply
Voting rights provided
Centrelink Reference Number (CRN) (if known)
Entitlement to dividends
Entitlement to capital distributions on wind up
Permanent address
5 Class (for example,
Ordinary, Class A, Class B) Number

Postcode Tick all that apply

Voting rights provided
If there are more than 3 directors, provide a separate Entitlement to dividends
sheet with details.
Entitlement to capital distributions on wind up

Mod(PC).2005
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 Continued Continued
6 Class (for example, 2 Name
Ordinary, Class A, Class B) Number

Date of birth CRN (if known)

Tick all that apply / /
Voting rights provided
Entitlement to dividends Tick if related to: Director(s) Other shareholders
Entitlement to capital distributions on wind up Other office-holders
Details of the shareholding for this shareholder
If there are more than 6 shares issued, provide a
separate sheet with details. Class of share
Number

26 Give details of all shareholders and their shareholding Purchase price $

1 Name Date purchased shares / /

Class of share
Date of birth CRN (if known)
Number
/ /
Purchase price $
Tick if related to: Director(s) Other shareholders
Other office-holders Date purchased shares / /
Details of the shareholding for this shareholder
3 Name
Class of share
Number Date of birth CRN (if known)
Purchase price $ / /
Date purchased shares / / Tick if related to: Director(s) Other shareholders
Other office-holders
Class of share
Details of the shareholding for this shareholder
Number
Class of share
Purchase price $
Number
Date purchased shares / /
Purchase price $
Date purchased shares / /

Class of share
Number
Purchase price $
Date purchased shares / /

Mod(PC).2005
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 Continued Continued
4 Name 6 Name

Date of birth CRN (if known) Date of birth CRN (if known)
/ / / /

Tick if related to: Director(s) Other shareholders Tick if related to: Director(s) Other shareholders
Other office-holders Other office-holders
Details of the shareholding for this shareholder Details of the shareholding for this shareholder
Class of share Class of share
Number Number
Purchase price $ Purchase price $
Date purchased shares / / Date purchased shares / /

Class of share Class of share

Number Number
Purchase price $ Purchase price $
Date purchased shares / / Date purchased shares / /

5 Name 7 Name

Date of birth CRN (if known) Date of birth CRN (if known)
/ / / /

Tick if related to: Director(s) Other shareholders Tick if related to: Director(s) Other shareholders
Other office-holders Other office-holders
Details of the shareholding for this shareholder Details of the shareholding for this shareholder
Class of share Class of share
Number Number
Purchase price $ Purchase price $
Date purchased shares / / Date purchased shares / /

Class of share Class of share

Number Number
Purchase price $ Purchase price $
Date purchased shares / / Date purchased shares / /

If there are more than 7 shareholders, provide a

separate sheet with details.

Mod(PC).2005
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27 Has the shareholding for the company changed in the last 29 Has anyone gifted, transferred or sold for less than their
5 years? market value, any cash, investments, services, real estate
No Go to next question or other assets to this company since 7:30 pm AEST on
9 May 2000?
Yes Give details of the historical shareholding
This is referred to as ‘contribution’.
Include any loans which may have been written off,
waived or for any reason decided not to recover.
Market value is the price a willing but not anxious
purchaser is prepared to pay a willing but not anxious
seller for an item.
No Go to next question
28 Has the company had a change in circumstances since Yes Give details of each contribution
the last financial statements were prepared (for example,
Value of contribution
upturn or downturn in trade, business sold, changes in
wages paid by the company to you and/or your partner)? The value of:
• cash is the amount contributed
No Go to next question
• services is the gross amount normally
Yes Give details below charged by a qualified person for a similar
You will need to provide a copy service
of the evidence of the change in • real estate is the market value at the
circumstances. Evidence may include: time the property was transferred to the
• an Interim Profit and Loss Statement company.
• sale documents If the contribution was in the form of real
• a current Balance Sheet estate, you must complete the ‘Company real
• an Administrator’s or Liquidator’s estate details’ section (questions 43 to 74),
Report. about that real estate.
Name of contributor
Date change occurred
/ /
Date of birth
Change in circumstances since last financial statement
/ /

Is the person: Still living Deceased

Nature of the contribution: Gifted Transferred

Sold for less than market value
What was contributed?

Date of contribution Value of contribution

/ / $
Amount originally paid for contribution (if applicable)
$

If there is more than 1 contributor, provide a separate

sheet with details.

Mod(PC).2005
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30 Does the company hold any shares or securities in public 31 Does the company hold any managed investments?
companies?
Include:
Include: • investment trusts
• futures • personal investment plans
• options • life insurance bonds
• derivatives • friendly society bonds.
• rights or convertible notes Do not include:
• other securities including those not listed on a • conventional life insurance policies
securities or stock exchange. • funeral bonds
No Go to next question • superannuation or rollover investments
• investments purchased with a margin loan.
Yes Give details below
APIR code – is commonly used for fund managers to
You will need to provide a copy of identify individual financial products.
the latest statement detailing the
shareholding in each company. No Go to next question
Yes Give details below
1 Name of the public company or ASX code
You will need to provide a complete
copy of a document which gives
Number of shares held current details for each investment
(for example, certificate with number
of units or account balance).
2 Name of the public company or ASX code
1 Name of the fund manager

Number of shares held

Name of the product Number of units
and product option held (if applicable)

3 Name of the public company or ASX code

APIR code (if known) Value of the investment
$
Number of shares held
2 Name of the fund manager

4 Name of the public company or ASX code

Name of the product Number of units
and product option held (if applicable)
Number of shares held
APIR code (if known) Value of the investment
5 Name of the public company or ASX code $

3 Name of the fund manager

Number of shares held
Name of the product Number of units
and product option held (if applicable)
6 Name of the public company or ASX code

APIR code (if known) Value of the investment

Number of shares held $

If there are more than 6 public companies, provide a

separate sheet with details.

Mod(PC).2005
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 Continued 32 Does the company hold any shares or have any other
4 Name of the fund manager involvement in other private companies?
No Go to next question
Yes Give details below
Name of the product Number of units You will need to complete and return
and product option held (if applicable) a Private Company (Mod PC) form for
each of these companies if this has not
already been done.
APIR code (if known) Value of the investment
If you do not have this form, go to
$
www.

servicesaustralia.gov.au/forms
5 Name of the fund manager 1 Name of the company

Name of the product Number of units

Company ABN or ACN
and product option held (if applicable)

APIR code (if known) Value of the investment 2 Name of the company
$

6 Name of the fund manager Company ABN or ACN

Name of the product Number of units

and product option held (if applicable) 3 Name of the company

APIR code (if known) Value of the investment Company ABN or ACN
$

If there are more than 6 managed investments, provide 4 Name of the company
a separate sheet with details.

Company ABN or ACN

5 Name of the company

Company ABN or ACN

6 Name of the company

Company ABN or ACN

If there are more than 6 private companies, provide a

separate sheet with details.

Mod(PC).2005
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33 Is the company a beneficiary of or otherwise involved in 34 Does the company own any other assets?
(for example, made a loan, gift or transferred assets) a No Go to 36
private trust?
Yes Go to next question
No Go to next question
Yes Give details of each trust
35 Give details of other assets, except real estate, held by
You will need to complete and return a the company.
separate Private Trust (Mod PT) form
for each of these trusts if this has not Only an estimate of the asset value is needed. If a
already been done. professional valuation is required for any asset(s),
we may have the assets valued at no cost to you or
If you do not have this form, go to
the company.
www.

servicesaustralia.gov.au/forms
The company balance sheet usually shows assets at
1 Name of the private trust their historical or Written Down Values (WDV), not their
market value.

Trust Tick if this is a

TFN primary production asset
Trust Your estimate of the
ABN Type of asset current market value

2 Name of the private trust Plant and equipment $

Machinery $
Trust Vehicles $
TFN
Trust Livestock $
ABN
Stock $
3 Name of the private trust
Licences $

Trust Bank accounts $

TFN Other (describe)
Trust
ABN $

4 Name of the private trust $

$
Trust
TFN
Trust
ABN

If there are more than 4 private trusts, provide a

separate sheet with details.

Mod(PC).2005
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 Company liabilities 38 Does the company have any other liabilities?
No Go to next question
36 Does the company owe money to anyone, including Yes Give details for each liability
associates?
Include:
Include: • bank loans
• salaries and wages owing to a person • mortgages
• loans made to the company • fully drawn advances
• dividends allocated to a shareholder that have not • personal loans not provided in question 36.
yet been paid to the shareholder.
Collateral security is fall back security in the
For more information about ‘Associates’, refer to the Notes event that the primary security is insufficient.
Booklet.

No Go to 38 1 Type of liability Amount of liability

Yes Give details below $
1 Name of person or associate Current market
Asset secured against value of asset
$
Date of birth Amount owed
/ / $ Tick if this is collateral security
Tick if this is a primary production asset
Interest rate paid on the loan %
(if applicable) 2 Type of liability Amount of liability
2 Name of person or associate $
Current market
Asset secured against value of asset
Date of birth Amount owed
$
/ / $
Tick if this is collateral security
Interest rate paid on the loan %
(if applicable) Tick if this is a primary production asset

3 Name of person or associate 3 Type of liability Amount of liability

$

Date of birth Amount owed Current market

Asset secured against value of asset
/ / $
$
Interest rate paid on the loan %
(if applicable) Tick if this is collateral security
Tick if this is a primary production asset
If there are more than 3 people or associates, provide a
separate sheet with details. If there are more than 3 liabilities, provide a separate
sheet with details.
37 Is there a written loan agreement, witnessed by a third
party, of a loan made to the company from a person or
an associate?
No Go to next question
Yes You will need to provide a copy of each
loan agreement (if available).
A written loan agreement must be
signed by all parties to the agreement
and witnessed by a genuine third party.
Associates are not considered to be
genuine third parties.

Mod(PC).2005
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39 Did any shareholder, director, person or associate 40 Has the income received by the shareholder, director, person
(as defined in the Notes Booklet) receive, or were they or associate changed since the last financial year?
entitled to receive, any income from the company in the No Go to next question
last financial year?
Yes Give details below
Include:
Date change occurred
• wages
• salaries / /
• director’s fees Details of current income
• bonus shares
• an income or capital distribution
• superannuation contributions made on the person’s
behalf to a superannuation fund.

No Go to 41
Yes Give details of each person
1 Name 41 Did any director or shareholder receive, or were they
entitled to receive, any benefit from the company in the
last financial year?
Date of birth Include noncash benefits.
/ / A person may enjoy an indirect or direct benefit from a
company, for example, having the company pay their
Total wages entitled Total wages paid personal living expenses, or having access to, or use of
$ $ company assets.
Total superannuation entitled Total superannuation paid No Go to next question
$ $ Yes Give details of each director or shareholder
Other income type (for example, director’s fees, 1 Name
bonus shares)

Date of birth Type of benefit

Total other income paid Financial year of payment
/ /
$
Value Financial year of payment
Will the person receive this income
in the current financial year? No Yes $

2 Name 2 Name

Date of birth Date of birth Type of benefit

/ / / /
Total wages entitled Total wages paid Value Financial year of payment
$ $ $
Total superannuation entitled Total superannuation paid
3 Name
$ $
Other income type (for example, director’s fees,
bonus shares) Date of birth Type of benefit
/ /

Total other income paid Financial year of payment Value Financial year of payment
$ $

Will the person receive this income

in the current financial year? No Yes If there are more than 3 people, provide a separate
sheet with details.
If there are more than 2 people, provide a separate
sheet with details.

Mod(PC).2005
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42 Does the company own any real estate?
Only include real estate held in the company name.

No Go to 75
Yes How many properties does the company hold?

If the company owns more than 1

property, complete a separate ‘Company
real estate details’ section (questions
43 to 74) for each property.
Go to next question

Mod(PC).2005
13 of 20
Company real estate details

43 Name of the company which owns the real estate 47 What is the legal description of the property
(for example, lot, section or parish. This may appear on the
rates notice)?
If the property is made up of more than 1 title, give
Company ABN details for each separate title.

About the property

Provide a copy of the latest council rate/valuation
notice.
If you need to complete this section for more than 1 property,
copy pages 14 to 18 before you answer the questions.
48 What is the estimate of the current market value of the
property, including land, buildings and water assets
44 Address of the property (for example, water rights, allocations or licences)?
You do not need to have the property professionally
valued. We may have the property valued at no cost
to you.

$
Postcode
Country (if not in Australia) Provide a copy of the water rights, allocation or
licence documents, if applicable.

49 Is there a residence on the property?

45 What date did the property become an asset of the company? No Go to 64
/ / Yes Go to next question

46 What type of property is this? 50 Does any shareholder or director live on the property?
Vacant land No Go to 64
Bush block Yes Go to next question
Home office/business
House 51 Is the property larger than 2 hectares (5 acres)?
Self contained flat (part of or No Go to 53
attached to a residence) Yes Go to next question
Units/flats/town house
Retail premises 52 What is the estimate of the value of the residence and
Commercial premises surrounding 2 hectares (5 acres)?
Industrial premises $
Farm (or hobby farm)
Market garden 53 Does the property have more than 1 title document?
Residential block larger than No Go to 55
2 hectares (5 acres)
Yes Go to next question
Other Give details below

Mod(PC).2005
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54 What is the estimate of the value of the residence and 59 Is the property used to produce an income?
surrounding title? No Go to next question
$ Yes Go to 62
Provide the legal description and area of the title on
which the residence sits. 60 Is there any reason that prevents the company from using
the property to produce an income?
No Go to 62
Yes Go to next question

61 Why is the property not being used to produce an income?

Tick all that apply
Provide a copy of each title deed. Rural residential block
Land is not viable for commercial
or agricultural use
55 Is the person who lives on the property (or their partner) Caring responsibilities
currently over Age Pension age and receiving, or claiming: Health reasons
• Age Pension Zoning restrictions
• Carer Payment Environmental restrictions
• Pension Bonus Bereavement Payment
Other Give details below
• Department of Veterans’ Affairs Age Service Pension?
No Go to 63
Yes Go to next question

56 Has the property been their home property for 20 years or 62 How is the property currently used?
more continuously? Tick all that apply
No Go to 63 Do not currently make any use of
Yes Go to next question the property
Primary production
57 Does the person (and/or their partner) or a family member Rural residential only
use the property to support themselves? Leased
No Go to next question Other commercial or business
Yes Describe how they use the property to support use (for example, commercial
themselves kennels)
Hobby farm
Other Give details below

58 Is there any potential commercial use of the property

(for example, subdividing, agistment, hobby farming)?
No Go to next question
Yes Describe the potential commercial use 63 Have 2 or more titles been amalgamated after 9 May 2006?
No
Yes

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64 Does the company have 100% ownership of the property? 67 Describe all buildings on the property
No Go to next question This will help us to value the property.
Yes Go to 66
1 What is the approximate floor How old is the
area in square metres? building?
65 Who else owns the property?
Percentage
Name of person/entity owned Type of construction
Exterior (for example, brick, timber)
%
%
Interior (for example, plaster, not lined)
%

If there are more than 3 owners, provide a separate Roof (for example, metal, tiles)
sheet with details.

General condition (for example, good, fair, poor)

66 What is the area or dimensions of the property?
Complete one of these measurements only.
Total number of flats/units in the
Area in hectares complex (if applicable)
For residential building, number of
or Area in acres bedrooms
Number of other rooms
or Area in square metres (excluding laundry, bathroom, toilet)
or Dimensions X 2 What is the approximate floor How old is the
area in square metres? building?
If the property is made up of more than 1 title, provide
a separate sheet with details of the area or dimensions
for each title. Type of construction
Exterior (for example, brick, timber)

Interior (for example, plaster, not lined)

Roof (for example, metal, tiles)

General condition (for example, good, fair, poor)

Total number of flats/units in the

complex (if applicable)
For residential building, number of
bedrooms
Number of other rooms
(excluding laundry, bathroom, toilet)

If there are more than 2 buildings, provide a separate

sheet with details.

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 Property financial details 71 Are there any circumstances affecting the value of the
property?
68 Is the property mortgaged or encumbered? This may include details such as:
No Go to next question • no water on property for grazing livestock
Yes Give details below • lack of adequate fencing
• hills
Date of loan Interest rate
• rocky ground
/ / %
• natural bushland
Amount of the loan Balance of the loan • unusual title.
$ $
No Go to next question
Name of finance provider
Yes Give details below

Provide the:
• mortgage or loan agreement(s) showing which
assets or properties are held as security
against the loan (if applicable)
• latest statement of each loan account.

69 Have any other assets or properties been used to secure the

loan to purchase this property? 72 If the property is hard to locate, give full directions or
No Go to next question provide a map.
Yes Give details below
Provide the following documents if this has not
already been done:
• mortgage or loan agreement(s) showing which
assets or properties are held as security
against the loan
• latest statement for each loan account.

Describe the asset or give the address of the property

used to secure the loan.

Estimated market value

$

If there is more than 1 asset or property used as security,

provide a separate sheet with details.

70 Does the company receive any rental income from the

lease of the property?
No Go to next question
Yes Give details below
Gross amount of rent received
(before tax and other deductions)
$

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 Privacy notice Authority to inspect the property

73 You need to read this 74 For more information about ‘Authority to inspect the
Privacy and your personal information property’, refer to the Notes Booklet.
The privacy and security of your personal information
is important to us, and is protected by law. We need I hereby authorise a licenced valuer to enter and inspect
to collect this information so we can process and the property for the purposes of a valuation in relation to
manage your applications and payments, and provide the Social Security (Administration) Act 1999.
services to you. We only share your information with I understand that if the property to be inspected is not
other parties where you have agreed, or where the law occupied by me, it is my responsibility to give the actual
allows or requires it. For more information, go to
www.
occupant reasonable notice, or such notice as is required
servicesaustralia.gov.au/privacy by agreement, of the inspection.
This authorisation does not permit the valuer to enter my
home, or any dwelling I may own, during the inspection,
unless invited to do so. A similar condition applies to the
home of any tenant involved.
I further understand that Centrelink or its representative
will contact me, or the person noted below, to arrange a
mutually convenient time for any inspection of the property.

Name of authorised officer

Authorised officer’s signature

On completion of this form,

print and sign by hand

Date
/ /
Person to be contacted by the valuer

Their daytime phone number

When you have completed a ‘Company real estate details’

section for each real estate property owned by the company
Go to next question

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 Checklist

75 Which of the following forms and documents are you (and/or your partner) providing with this form?
You must provide copies of documents. The copies will not be returned.

Documents you must provide Documents you may need to provide

Tick all that apply If you are not sure, check the question to see if you
should provide the documents.
Details of your wages from this company
(if you answered No at question 9) Tick all that apply
Go to 76 Private Trust (Mod PT) form
(if you answered Yes at question 15 and/or 33)
Personal Income Tax Return for you
A copy of the evidence of change in circumstances
Personal Income Tax Return for your partner if they (if you answered Yes at question 28)
are involved with the company A copy of the latest statement detailing the share
Latest Income Tax Return for the company holding in each company
(if you answered Yes at question 30)
Profit and Loss Statement for the company A copy of a document which gives details for each
Depreciation Schedule for the company investment
This must show depreciation as claimable under (if you answered Yes at question 31)
Division 40 of the Income Tax Assessment Act 1997. Private Company (Mod PC) form
Instant Asset write-off claimed under Division 328-D (if you answered Yes at question 32)
of that Act are not allowed for social security Copies of any written agreements concerning loans
purposes. from a person or an associate to the company
Balance sheet for the company (if you answered Yes at question 37)
Notes to and forming part of the accounts A completed ‘Company real estate details’ section
(If applicable) for each real estate property owned by the
company
Trading account details for the company (if you answered Yes at question 42)
(If applicable)
A copy of the council rate/valuation notice for each
Profit and Loss Statement(s) for all income sources property owned by the company
and/or balance sheet for the company for the (at question 47)
current financial year if the most recent completed A copy of the water rights, allocation or licence
year is not an accurate reflection of the current documents, if applicable
circumstances of the company (if applicable) (at question 48)
Additional Profit and Loss Statement(s) because the A copy of each title deed
company derives income from more than 1 source (required at question 54)
(if applicable)
The mortgage or loan agreement(s) showing which
If you are not able to lodge any of the required assets or properties are held as security against
documentation, give an explanation below the loan (if applicable) and latest statement of each
loan account
(if you answered Yes at question 68 or 69)
We may request further documents that relate to the
company.

Go to the next page

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 Privacy notice Returning your form
You can return this form and any supporting documents:
76 You (and your partner) need to read this
• online using your Centrelink online account.
Privacy and your personal information For more information, go to www.

The privacy and security of your personal information servicesaustralia.gov.au/submitdocumentsonline

is important to us, and is protected by law. We need • in person at one of our service centres, if you are not able
to collect this information so we can process and to use your Centrelink online account.
manage your applications and payments, and provide
services to you. We only share your information with
other parties where you have agreed, or where the law
allows or requires it. For more information, go to
www.

servicesaustralia.gov.au/privacy

Declaration

77 I declare that:
• the information I have provided in this form is complete
and correct.
I understand that:
• if submitting this document as part of a claim, the claim
may not be accepted unless supporting documents
are lodged at the same time as the claim. The only
exception will be if I am waiting for medical evidence
or other documents from a third party.
• the company may be reviewed but I must tell
Centrelink of any changes to the company’s
circumstances that may impact my payment within
14 days of the change(s) occurring, or within 28 days if
I live outside Australia. For example:
–– changes in the company’s shareholding, income or
assets
–– gifts made or received, or
–– distributions made.
• Centrelink can make relevant enquiries to make sure I
receive the correct entitlement.
• giving false or misleading information is a serious
offence.

Your signature
On completion of this form,
print and sign by hand

Date
/ /

Your partner’s signature

On completion of this form,
print and sign by hand

Date
/ /

Print Clear

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