Ending a child support assessment form - Department of Human ...

Ending a ChildSupport AssessmentWhen to use this formHelp in other languagesWhen you end an assessment you are asking the AustralianGovernment Department of Human Services to stop calculating howmuch child support the paying parent should pay to support yourchild/ren.You can still receive child support under a private arrangement oragreement. If your circumstances change, you can reapply to us tocalculate and collect child support.Note: Both parents need to sign this form.This form is available for printing online, go to our websitehumanservices.gov.au/forms or call us on 131 272 Monday toFriday between 8.30 am and 4.45 pm, local time. Note: Call chargesapply – calls from mobile phones may be charged at a higher rate.To complete this form• Print using BLOCK LETTERS• Use blue or black pen• Tick where applicable • Sign the formWhere do I send this form?Send the completed form to:Department of Human ServicesGPO Box 9815MELBOURNE VIC 3001orFax: 1300 309 949Korean(TIS), 131 450For more informationFor more information, go to our websitehumanservices.gov.au/childsupport or call us on 131 272.1671.12051 of 4

1 Your Child Support Reference Number— — —(as shown on your Child Support Letters)If you do not have a Child Support Reference Number, pleasequote your Tax File Number (TFN).— —9 What is the name of the person who is required to pay youchild support payments?Mr Mrs Miss Ms OtherFamily nameFirst given name2 What are your personal details?Mr Mrs Miss Ms OtherOther given namesFamily nameFirst given name10 Date of birthOther given names11 Postal address3 Date of birth12 Home phone4 Postal address( )13 Work phone( )5 Home phone( )14 Mobile phone6 Work phone( )15 Email@7 Mobile phone8 Email@1671.12052 of 4

16 Details of the child(ren) you want to end the child supportassessment forChild oneFamily name17 Please state your reason for wanting to end the child supportassessmentFirst given nameOther given namesDate of birthChild twoFamily nameFirst given nameOther given namesDate of birthChild threeFamily nameFirst given nameOther given namesDate of birth18 Do you receive Family Tax Benefit Part A, at more than the baserate?NoGo to the next questionIf there are more than three children, please attach a separatesheet with details.YesIf you receive FamilyTax Benefit at more thanthe base rate you cannotend an assessment unlessthere are exceptionalcircumstances.Your request to endan assessment will bereferred to Centrelinkfor approval and theywill contact you to letyou know whetheryour request has beenaccepted or not.1671.12053 of 4

19 On what date do you want the assessment to end?We can calculate a date to ensure there is no underpayment oroverpayment.Would you like us to do this?NoSelect your own dateYes Go to question 2220 If there are any payments still owing to us, do you want us tocollect them for you?No Go to question 22Yes21 Would you like us to collect the full amount?22 StatementI declare that:NoGo to the next questionHow much?(must be less thanthe full amount)$Yes Go to question 22• the information provided in this form is complete andcorrect.I understand that:• giving false or misleading information is a serious offence.Your signaturePrivacy and your personal informationCentrelink, Medicare Australia, Child Support and CRS Australiaare services within the Australian Government Department ofHuman Services (Human Services).Your personal information is protected by law, including thePrivacy Act 1988. Your information is collected for SocialSecurity, Family Assistance, Medicare, Child Support and CRSpurposes. This information may be required by the powersprovided within each services’ legislation or voluntarily givenby you when you apply for services or payments.Your information will be used for the assessment andadministration of payments and services. Your information mayalso be used within Human Services, where you have providedconsent or it is required or authorised by law. Human Servicesmay disclose your information to Commonwealth departments,other persons, bodies or agencies ONLY where you haveprovided consent or it is required or authorised by law.You can get more information about privacy by going to ourwebsite humanservices.gov.au/privacy or requesting a copyof the full privacy policy at one of our Service Centres.What if I have a complaint?Step One:Contact us and speak to your Customer Service Officer who willtry to solve the problem.Step Two:If you are not satisfied with the outcome, ask to speak to theirmanager.Step Three:If you are still not satisfied, call our Complaints Service on132 919 and speak to a Complaints Officer.If you feel that we have been unable to successfully resolveyour complaint, you can escalate your concerns by contactingthe Commonwealth Ombudsman.How can I report suspected fraud?If you have information about someone who is misusinggovernment services, please phone the Australian GovernmentServices Tip-off Line on 131 524.The tip-off line allows you to confidentially report fraud againstthe Department of Human Services.-DateSignature of Receiving Parent-Date1671.12054 of 4