Life Certificate form - Department of Human Services

Life Certificate
To be completed by customer
Customer’s responsibilities
1 Your personal details
• You are required to have this certificate verified (see page 2) by one of the people listed below:
- notary public/advocate
- priest or religious leader
- Justice of the Peace
- magistrate
- Australian official at an embassy,
- solicitor
consulate or high commission
- physician.
- local social security authority
• official papers or documents which include a photograph of yourself must be presented
as identification. Suitable documents include:
- passport
- other official government documents.
- identification card
• any costs involved in getting this certificate verified will be your responsibility.
• if you fail to return this certificate within 6 weeks your pension may be stopped.
Title Mr Mrs Miss Ms Other
Family name
First given name
Second given name
Date of birth
Centrelink Reference Number
Day Month Year
Sex Male Female
2 What is your CURRENT
relationship status?
From 1 July 2009, Centrelink
recognises both opposite-sex and
same-sex relationships. This
includes de facto relationships
and relationships registered under
Australian state or territory law. If
you and your same-sex partner
have married or had your
relationship registered outside
Australia, please indicate your
relationship as ‘partnered’ in this
list.
Select ONE option below that best
describes your current relationship
status.
Married
Registered relationship
(opposite-sex or same-sex relationship
registered under Australian state or territory law)
Partnered
(living together in an opposite-sex or
same-sex relationship, including de facto)
Separated
(previously lived with an opposite-sex or
same-sex partner, including in a marriage,
registered or de facto relationship)
Divorced
Date of marriage
Date of registration
Date you started living
together as a couple
Date of separation
Date of decree absolute
Day Month Year
Go to 4
Day Month Year
Go to 4
Day Month Year
Go to 4
Day Month Year
Go to 3
Day Month Year
Go to 3
Widowed
(previously partnered with an opposite-sex
or same-sex partner, including in a marriage,
registered or de facto relationship)
Date of partner’s death
Day Month Year
Go to 4
Never married or lived with a partner
Go to 4
3 Do you live in the same home as
your former partner?
No
Yes
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4 Contact details Address
Contact phone number
Country
Country ( ) Area
code ( )
5 Statement
If the customer is unable to sign due
to physical, psychiatric or intellectual
disability, or due to illiteracy, another
person may sign on their behalf by
completing question 6 (below).
I declare that:
I understand that:
Your signature
Date
• the information I have given in this form is complete and correct.
• giving false or misleading information is a serious offence.
Day Month Year
6 Detals of person signing on
behalf of the customer (if
customer is unable to sign)
Name of person
Relationship to customer
Please attach evidence
of the customer’s
inability to sign this form
(e.g. legal or medical
documents, Social
Worker report).
Address
Contact phone number
Signature of person signing
on behalf of the customer
Country
Country ( ) Area
code ( )
Date
Day Month Year
If the customer wants to arrange for another person or organisation to enquire or act on his/her behalf
when dealing with Centrelink, please tick this box and we will send you the required form.
You must now take this form to an authorised person to confirm your identity (see below).
To be completed by
authorised person
• As a person authorised to verify the identity of a customer, it is essential that you sight adequate
identification to satisfy yourself as to the person’s true identity.
• Satisfactory identification would be official papers or documents that include a photograph of the
person. Suitable documents include:
- passport
- identification card
- other official government documents.
• If a person is unable to provide any photographic identification, you should be certain of their
identity from other sources before verifying their identity.
• The person’s signature should be certified from official documents.
• To verify the person’s identity complete the details below.
• This form must be signed and stamped with your official stamp or seal or an official document
provided that confirms that the customer is alive.
7 Details of authorised person Title
Mr Mrs Miss Ms Other
Family name
Given name(s)
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8 Contact details Address
Contact phone number
Country
Country ( ) Area
code ( )
9 Documentation provided for
identification of the customer
10 Statement
I declare that:
I understand that:
Signature of
authorised person
• I am satisfied as to the identity of the customer.
• giving false or misleading information is a serious offence.
• personal information is protected by Australian law.
Date
Day Month Year
Official stamp or seal
of authorised person
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