Permanent Residential Aged Care - Request for a …

1 1 of 31 Permanent Residential aged CareRequest for a CombinedAssets and income AssessmentUse this form to give details about your assets and income if you are entering, or have entered,a Residential aged care service, so we can determine: the means tested fee you may be required to pay for your care , and whether you qualify for additional Government assistance with your accommodation you complete this form before entering a Residential care service, the initial fee notification adviceyou receive will be valid for 120 days unless there is a significant change in your circumstancesin which case you will be required to notify : This assessment is NOT relevant to either respite care or, Home care should have received the booklet Information you need to know about your claim forPermanent Residential aged care Request for a combined Assets and income Assessmentwith this form. In this claim, this booklet will be referred to as the Information Booklet.

2 If you donot have this booklet, go to our website or call us onFreecall 1800 227 in this formPlease use black or blue in BLOCK boxes like this with a or .Where you see a box like this Go to 5 skip to the question number shown. You do not needto answer the questions in to use this formHelp with your formIf you want information about how to answer the questions in this form, and: you receive a Centrelink income support payment, or you are a self-funded retiree,call the Department of Human you want information about how to answer the questions in this form, and: you receive a Department of Veterans Affairs income support payment,call the Department of Veterans general information on fees and charges applying to aged care , go to My aged care website or call us on Freecall 1800 200 you need specific advice on completing this form or on applying for financial hardship assistance,go to our website or call us on Freecall 1800 227 form is not an application for Financial Hardship Assistance.

3 For information about FinancialHardship Assistance, go to our website or call us on Freecall 1800 227 Australian Government Department of Human Services or the Department of Veterans Affairsrequires details about your combined assets and income for Permanent Residential aged care information you provide will be used to calculate your aged care fees and charges. Theinformation will also be used to calculate the amount of Government assistance the provider mayreceive on your you do not provide your assets and income details, you may be required to pay the maximumfee and of this of 31 For more informationGo to our website or call us on 1800 227 you need a translation of any documents for our business, we can arrange this for you free speak to us in languages other than English, call 131 you receive a payment from the Department of Veterans Affairs (DVA), call DVA on 133 254,if you live in regional Australia call on Freecall 1800 555 : Call charges apply calls from mobile phones may be charged at a higher to 1800 numbers are free of charge from a fixed you have a hearing or speech impairment you can contact the TTY service on Freecall 1800 810 586.

4 A TTY phone is required to use this informationPrivacy and your personal informationYour personal information is protected by law, including the Privacy Act 1988, and is collected bythe Australian Government Department of Human Services for the assessment and administrationof payments and services. This information is required to process your application or information may be used by the department or given to other parties for the purposes ofresearch, investigation or where you have agreed or it is required or authorised by can get more information about the way in which the Department of Human Services willmanage your personal information, including our privacy policy at by requesting a copy from the your formCheck that you have answered all the questions you need to answer and that you have signed anddated this form. if you receive an income support payment from Centrelink, return your form and any additionaldocuments to:Department of Human ServicesResidential CareReply paid 7821 Canberra BC ACT 2610 if you receive an income support payment from the Department of Veterans Affairs, return yourform and any additional documents to:Department of Veterans AffairsAged care Assets AssessmentsGPO Box 9998In your capital cityNote:ACT residents should post their form to SydneyNT residents should post their form to Adelaide if you do NOT receive an income support payment from either Centrelink or theDepartment of Veterans Affairs, return your form to the Department of Human Services(address above).

5 You should do this before you enter care (if possible) to make sure that your assets and income foraged care fees purposes can be calculated as quickly as possible. If you enter Residential carewithout having a means test assessment , you could be asked to pay the maximum aged care details (the person the assessment is for)3 of nameOtherFamily nameFirst given nameSecond given nameMsMissMrsMrYour sex2 MaleFemaleYour date of birth3/ /Phone number()Is this a silent number?NoYesEmail@Please read this before answering the you sure you need to complete this form?Do not complete this form until you have readPermanent Residential aged care combined assets andincome assessment in the Information Booklet and arecertain that you need an more information, call us on Freecall 1800 227 number()Is this a silent number?NoYesPostcodeYour home address6 Please read this before answering the your postal address or, if you will be nominatinga contact person and you want your mail to be sent tothem, write their postal address address8 Are you currently receiving a payment from eitherCentrelink or the Department of Veterans Affairs?

6 NoYe sGo to next questionCentrelink Reference Number (if known)Name of Centrelink paymentGive details belowYouDepartment of Veterans Affairs reference numberAmount paid per fortnight$Name of Department of Veterans Affairs paymentFor more information, refer to What is an income supportpayment? in the Information contact detailsPlease read this before answering the you provide an email address or mobile phone number,you may receive electronic messages (SMS or email)from us. To read the Terms and Conditions, go to ourwebsite or visit one of ourService to next question5 Are you already in Residential aged care or in hospitalawaiting entry to a Residential aged care home?NoYesGive details belowPostcodeYour previous home addressGo to 7 CLK0SA457 15024 of you currently living in Residential aged care ?NoYe sGo to next questionName of the aged care home you currently live inGive details belowCurrent balance of any lump sum accommodation bondyou have paid to the aged care home$For more information, refer to aged care fees andcharges in the Information balance of any lump sum refundableaccommodation deposit you have paid to the aged carehome$Current amount per day of any accommodation chargeyou are paying to the aged care home$Current amount per day of any daily accommodationpayment you are paying to the aged care home$10 Are you (and/or your partner) a veteran or dependant of adeceased veteran?

7 NoYe sGo to 13Go to next question11 Did you (and/or your partner) receive a payment of $25,000from the Australian Government as compensation forinternment by: North Korean forces during the Korean war, or Japanese or Axis forces during World War II?NoYe sGo to next questionNote: The amount of these payments isdeducted from the value of your assets if youhave received to next questionGo to 1913Do you have a partner?NoYe sGo to next question14 Your partner s nameFamily nameFirst given nameSecond given nameYour partner s date of birth16/ /PostcodeYour partner s Permanent address17 OtherMsMissMrsMr15 Your partner s sexMaleFemalePlease read this before answering the service is service in a war or war likeoperations during which you incurred danger from hostileforces of the you have such service, some Department of Veterans Affairs payments (if you receive them) may be exemptedfrom the income assessment for aged care fees you (and/or your partner) have qualifying service?

8 NoYe sGo to next questionGive details belowTick appropriate box(es)I have qualifying serviceMy partner has qualifying serviceAdmission details5 of 31 Option 2: My current admission to Residential will need to answer the following questionsbased on what your circumstances were on yourcurrent date of admission to to 20 Option 1: My previous admission to Residential will need to answer the following questionsbased on what your circumstances were on yourprevious date of admission to to your partner currently receive a payment from eitherCentrelink or Department of Veterans Affairs?NoYe sGo to next questionCentrelink Reference Number (if known)Name of Centrelink paymentGive details belowYour partnerDepartment of Veterans Affairs reference numberAmount paid per fortnight$Name of Department of Veterans Affairs paymentFor more information, refer to What is an income supportpayment? in the Information read this before answering the information: How you answer question 19depends on whether this assessment is for aprevious admission to Residential care OR if it is for acurrent admission to Residential care OR afuture admission to Residential assessment can only be for ONE of the 4 optionslisted do you want this assessment for?

9 Tick ONE box ONLYO ption 4: I am an aged care resident who wasalready in Permanent Residential care on30 June will need to answer the following questionsbased on your current circumstances which willbe referred to as the relevant dateNote: This assessment will NOT be considered asa formal Request to opt-in. Opting-in to the newarrangements must be made in was that date of admission to care ?20/ /Answer the following questions basedon what your circumstances were onthis admission date, which will bereferred to as the relevant to next questionGo to 38 Option 3: A future admission to permanentresidential will need to answer the following questionsbased on your current circumstances which willbe referred to as the relevant to 38 Your home details6 of much was your home sold for?25$On what date was your home sold?/ /Attach documentation which gives details of thesale of your home, for example, a solicitor ssettlement much was your home worth at the time the title wastransferred?

10 $On what date was the title transferred?/ /Did you receive anything in return for the title transfer?NoYesHow much did you receive?$Go to 70 Attach documentation which gives details of thetransfer, for example, a solicitor s letter or to 7027 What amount was (or will be) paid to you (and/or yourpartner) due to the retirement village unit being vacated?$When was (or will) this amount be paid to you (and/or yourpartner)?/ /Attach documentation which gives details of theamount paid under the retirement to 70On the relevant date of admission to care , was your home:28a mobile home, or caravan, orboat or a similar dwellingGo to next questiona retirement village unit,including one for which an entrycontribution was paidGo to next questiona unit, flat or duplex that was notin a retirement villageGo to 34a house (including a dwellinglocated on a farm)Go to 34 Tick ONE box ONLYWhat is your estimate of the net market value of your (andyour partner s) household contents and personal effects onthe relevant date of admission to care ?