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You have applied as an independent person under the ' Unreasonable to live at home' guidelines. To meet these guidelines it must be unreasonable for you to live at home because: of extreme family breakdown (other than normal parent/adolescent conflict), or of serious risk of your physical or mental health if you continue to live at home, or your parent(s) cannot provide a suitable home as they do not have stable accommodation. If you live away from home to undertake study, look for work or undertake your Australian Apprenticeship, you may be entitled to an away from home rate instead.
If you need help to fill in this form or you need more information about the questions, please call us on 132 490. To speak to us in languages other than English, call 131 202. Note: Call charges apply calls from mobile phones may be charged at a higher rate.
If you have a hearing or speech impairment Interpreters and translations What else you will need to provide
TTY service Freecall 1800 810 586. A TTY phone is required to use this service.
If you need an interpreter or translation of any documents for our business, we can arrange this for you free of charge. You will also need to provide: a Youth Allowance or ABSTUDY Unreasonable to live at home Statement by Parent(s)/Guardian(s) form (SY016). If your parent(s) are separated, each parent may need to complete an SY016 form. a Youth Allowance or ABSTUDY Unreasonable to live at home Statement by Independent Third Party form (SY017).
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Please use black or blue pen. Print in BLOCK LETTERS. with a or . Mark boxes like this Go to 5 skip to the question number shown. You do not need Where you see a box like this to answer the questions in between.
Check that you have answered all the questions you need to answer and that you have signed and dated this form. If you return required documents (and this form): online you can submit your documents online if you are registered for online services. To access online services or to find out how to register, go to humanservices.gov.au/submitdocumentsonline
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by post we will sight and record your documents, which may include copying, and return the originals to you by registered post. in person we will sight and record your documents, which may include copying, and return the originals to you. Return this form and all additional documents to one of our Service Centres or post directly to: Department of Human Services Student Services Reply Paid 7804 CANBERRA BC ACT 2610 If you are lodging documents online, to establish your identity, we may still require you to attend an office to provide orginial documents. For more information on how to lodge documents online, go to humanservices.gov.au/submitdocumentsonline
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Give details below Date you returned home to live (or estimate of date returned) / / / / / / / /
Family name
Date you left home (or estimate of date left) First given name / / / / / / /
If you have left home on more than 4 occasions, attach a separate sheet with details.
Who do you live with now? Partner (married, registered partner or de facto of the opposite-sex or same-sex) Friends In a refuge/hostel Alone Other
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Give details below
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Please read this before answering the following question. Parent means a natural or adoptive parent, or a person who is legally responsible for you. If your parent(s) are separated we need to know details about each of them. Do you live with your parent(s)? No Yes
Address
CLK0SY015 1312
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Address
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Persons name
( Mother
) Father Guardian
Their address
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15 When last did you have contact with your other parent?
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How long have they looked after you? (e.g. number of days/months/years)
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Give details below
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Give details below
Persons name
Their address
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No
Yes
No
Yes
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Has your relationship improved or deteriorated? Improved Deteriorated
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Give details below Include: type of contact (e.g. phone call, visit) how often contact has been made who initiated the contact.
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Give details below
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Give details below
Where do you want your payment made? The bank, building society or credit union account must be in your name. A joint account is acceptable. Name of bank, building society or credit union Branch where your account is held Branch number (BSB) Account number (this may not be your card number) Account held in the name(s) of
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IMPORTANT INFORMATION 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.
32 Is there any other information you can provide that will help us
decide if it is unreasonable for you to live at home with your parent(s)/guardian(s)? No Yes
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Give details below Attach any other documents/reports etc. that you wish to provide.
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35 Statement
I declare that: the information provided in this form is complete and correct. I understand that: giving false or misleading information is a serious offence. the Australian Government Department of Human Services can make relevant enquiries to ensure I receive the correct entitlement. Your signature
Date / /
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