Locked Bag 7834 Canberra Bc, ACT 2610

Your Reference
Number 408 026 128C
CLK2SU523 G264019177001 Date of issue 21 September 2016
RETURN DATE: Immediately
Rent Assistance will cease unless the requested
information is provided by the return date.

Return address

Miss Zarah Duffy Centrelink

31 Lyrebird Ridge Rd Reply Paid 7800
SPRINGBROOK QLD 4213 Canberra BC ACT 2610

Returning your form

Please fold the form and place it in the
reply paid envelope so that THIS ADDRESS
appears in the envelope window.

SU523.1507 (Page 1 of 3)

Rent Certificate
/AHA/SU523

PART A — Your accommodation details 6 Which of the following best describes your
1 What is your residential address (not a PO box)? accommodation?
Private house, unit, apartment, flat Go to 8
Caravan, cabin, mobile home Go to 8
Granny flat Go to 8
Postcode Community Housing Go to 8
Defence Housing Go to 8
2 What date did you start living at this address?
Public Housing Go to 7
/ /
Boarding house, hostel, private hotel Go to 9
3 Do you (and/or your partner) own a home or have a Hospital, disability housing Go to 9
mortgage? Aged care hostel, nursing home,
This includes caravan, cabin, boat, mobile home. retirement village
No Go to 5 Attach documents to verify the
Yes Go to next question details of your entry contribution. Go to 13
4 Do you (and/or your partner) own a home but live
Other (e.g. boat, refuge, relocatable
elsewhere? home) Give details below
No Go to next question
Go to 8
Yes What is the reason for not living in your
home (e.g. travelling, temporary care)? 7 Tick boxes that describe your public housing
accommodation:
You are the primary tenant (that is,
your (and/or your partner’s) name is
How long will on the tenancy agreement/lease with
you be away? public housing) Go to 13
You are not the primary tenant and:
5 Do you (and or your partner) pay rent or fees for the
The primary tenant pays market rent
accommodation listed at question 1?
The primary tenant lives with you and
No When did you stop paying?
your (and/or your partner’s) income has
/ / Go to 13 been taken into consideration by the
public housing authority when
Yes Go to next question calculating the rent

SU523.1507 408 026 128C

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 8 Do you share your accommodation with other people? 12 Details of your landlord, authorised agent or person you
No Go to next question (and/or your partner) pay rent to
Yes Give details below Full name

1 Person’s name Age

Address

When did they move in Relationship to you

/ /
Their share of the Do they own Postcode
rent/lodgings the home? Phone ( )
$ per No Yes number

13 Statement
2 Person’s name Age I declare that:
• the information I have provided in this form is
complete and correct.
When did they move in Relationship to you
I understand that:
/ / • giving false or misleading information is a serious
offence.
Their share of the Do they own
• the Australian Government Department of Human
rent/lodgings the home?
Services can make relevant enquiries to make sure I
$ per No Yes receive the correct entitlement.
Signature
If you share with more than 2 people, attach a
separate sheet with details.

9 Which of the following best describes the amounts you

(and/or your partner) pay to live in your home? Date / /
Phone ( )
Make sure you only advise the amount you (and/or number
your partner) actually pay - that is, the total rent paid
for the property minus any subsidy/rebate or PART B does NOT need to be completed if:
contributions from other people. • you have attached a signed copy of the current lease
or tenancy agreement, or
Private rent (rent, site/mooring fees only) • you (and/or your partner) currently live in a boarding
house, guest house, hostel, private hotel, hospital,
$ per
refuge, retirement home, retirement village, disability
Board and lodgings (meals and accommodation housing.
only)
$ per PART B - To be completed by your
landlord, authorised agent or person you
Note: If you only pay lodgings or can separate lodging
pay rent to.
from board and lodging, record below.
Landlord, authorised agent or rent collector’s statement
Lodgings (accommodation only)
I confirm that:
$ per • the details on this form are complete and correct to the
best of my knowledge.
10 When did you (and/or your partner) start paying this
I understand that:
amount?
• giving false or misleading information is a serious
/ / offence.
Signature
11 What is the total amount of rent paid for the property?
Make sure the total rent amount does not exceed the Name
total rent paid by each sharer listed in question 8 (please print)
PLUS the rent amount paid by yourself listed in
question 9. Phone number ( )

$ per Date / /
Office Use Only
Tenancy Agreement/Lease sighted and checked

Logon Date / /

SU523.1507 408 026 128C 2 of 3

160923 BCH - 106976 1 BL- 2
 Please read this information.
You do not need to return this page, keep it for future reference.
Definitions
Rent
Rent is the amount payable by a person as a
condition for occupying their principal home and
includes amounts paid per day, week, fortnight, four
weeks or calendar month for:
• board and lodgings (includes meals and
accommodation), or
• lodgings (accommodation only), or
• site fees for a caravan, tent, mobile or other
structure, or
• mooring fees for a vessel, or
• service and maintenance fees provided in a
retirement village, hostel or aged care facility.
Partner
Partner includes married, registered partner or de
facto of the opposite-sex or same-sex.
Sharing accommodation
Sharing your accommodation means that you have
the right to use a bedroom, kitchen or bathroom with
one or more persons. This includes:
• all family members (partner, parents, children),
and
• people who regularly stay at your home; and
• people who may work away from the home
(miners, members or armed services, truck drivers
etc.)
Landlord
A ‘landlord’ can be:
• the person to whom you pay rent, or
• the owner of the premises you lease, or
• the real estate agent/agency managing the
premises, or
• the owner, manager or operator of a facility (such
as a caravan park).
Community Housing
Means any premises owned, or leased and managed
by, a Community housing organisation.
Disability Housing
Means any premises owned, or leased and managed
by, a Disability Services agency.
Public Housing
Means any premises owned, or leased and managed
by, a State or Territory government housing
authority.
Please go to our website
humanservices.gov.au/rentassistance for more
information.
When should I contact the Department of Human
Services?
You must tell the Department of Human Services
straight away if:
• you change your address, or
SU523.1507
2/1-1
• the amount of rent you pay changes, or
• you start or stop sharing your accommodation or
the number of people sharing changes, or
• you take in a subtenant, boarder or lodger, or
• you become partnered or separate from your
partner, or
• the amount of your income changes (this may
affect FTB payments), or
• children leave your home or return to live with you,
or
• you have difficulty getting a rent certificate
completed.
Your rights
If you do not agree with a decision we have made:
• Contact us so we can check the details and
explain the decision.
• Contact us and ask for a review of the decision.
We will change it if it is wrong.
• Contact the Administrative Appeals Tribunal (AAT)
if you do not agree with the review officer’s
decision.
• If you do not agree with the decision of the AAT
you may be able to appeal further. For more
information about the AAT, please go to
aat.gov.au
All of the above are free of charge.
If you do not agree with a decision we have made,
contact us as soon as possible. It is important to ask
for a review within 13 weeks of being notified about
the decision. If your request for a review is more than
13 weeks after being notified and the decision is
changed, you may only receive your entitlement from
the date you requested the review.
Privacy and your personal information
Your personal information is protected by law,
including the Privacy 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.
Go to humanservices.gov.au/feedback to give
feedback or call our Customer Relations Team on
1800 132 468 to make a complaint.
If we do not resolve your complaint to your
satisfaction, you can contact the Commonwealth
Ombudsman by going to ombudsman.gov.au or
calling 1300 362 072.
Note: Call charges apply from mobile phones.
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