MOD. Real estate details. When to use this form. Definition of a partner. For more information. If you have a hearing or speech impairment

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1 Real estate details MOD R Return this form online or to one of our Service Centres by Your Centrelink Reference Number When to use this form Definition of a partner For more information If you have a hearing or speech impairment Interpreters and translations What else you will need to provide You should use this form: if your home property is more than 2 hectares if your home property is on more than one (1) title if your home property is used for business purposes (regardless of the size of your property) if you own any real estate other than your home property in Australia or outside Australia if you or your partner are involved in a partnership, private company or private trust which owns any real estate if you are in a care situation and have been absent from your home property for 2 years or more if you have been temporarily absent from your home property for more than 12 months. Complete a separate form for each property. Additional forms may be obtained by going to our website or call us on or visit one of our Service Centres. For the Australian Government Department of Human Services purposes a person is considered to be your partner if you and the person are living together, or usually live together, and are: married, or in a registered relationship (opposite-sex or same-sex), or in a de facto relationship (opposite-sex or same-sex). We consider a person to be in a de facto relationship from the time they commence living with another person as a member of a couple. We recognise all couples, opposite-sex and same-sex. If you need help to fill in this form or you need more information about the questions, call us on: Disability and Carers Payments Employment Services Seniors Youth and Students To speak to us in languages other than English, call te: Call charges apply calls from mobile phones may be charged at a higher rate. TTY service Freecall 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. This form tells you which other documents you need to provide to support your claim. Depending on your circumstances, you may have to fill in other forms. 1 of 8

2 Filling in this form Returning your form(s) Please use black or blue pen. Print in BLOCK LETTERS. Mark 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 need 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. 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, all additional documents and any other forms you are required to complete to one of our Service Centres or online within 14 days to make sure you are paid from the earliest date possible. If you cannot return all the forms or documents within 14 days, contact us for extra time. For more information on how to access Online Services or how to lodge documents online, go to www. humanservices.gov.au/submitdocumentsonline 2 of 8

3 1 Your name 8 What type of property is this? Mr Mrs Family name Miss Ms Other Vacant land Bush block Home office/business First given name House Self contained flat (part of or attached to a residence) Units/flats/town house Second given name Retail premises Commercial premises Industrial premises 2 Your date of birth Farm (or hobby farm) Market garden Residential block larger than 2 hectares 3 Your Centrelink Reference Number Other Give details below 4 Your contact phone number ( ) 9 What is the legal description of the property (e.g. lot, section, parish, etc. this may appear on the rates notice)? 5 How many properties in Australia and/or outside Australia do you (and/or your partner) own or have an interest in? te: If the property is made up of more than 1 title, please provide details for each separate title. You will need to complete and attach a separate Real estate details form (Mod R) for each property you own. If you do not have this form, go to our website or call us on Attach a copy of the latest council rate/valuation notice. 6 Address of the property 10 What is the area or dimension of the property? Complete ONE of these measurements only. Area in hectares OR Area in acres Country (if not in Australia) Postcode OR OR Area in square metres Dimensions X 7 Did you (and/or your partner) purchase this property? Give details below Date of purchase If your property is made up of more than 1 title, attach a separate sheet with details of the area or dimensions for each title. 11 Give details of any water rights including allocations or licences either associated with the property or owned separately. Purchase price Attach a copy of the licence or allocation documents. CLK0Mod(R) of 8

4 12 What is the estimate of the current market value of the property, including land, buildings and water allocations? 18 What is the estimate of the value of the home and surrounding title? Give us an estimate of the value. You do not need to have the property professionally valued. We may have the property valued at no cost to you. Provide details of the title on which the home sits Description, area 13 Do you (and/or your partner) live on the property? Go to 27 Go to next question 14 Are you (and/or your partner) using any rooms or buildings of your principal home solely for business (e.g. rooms used exclusively for a bed and breakfast business)? What is the value of the rooms or buildings of your principal home used solely for business? Is any portion of the land surrounding your principal home used primarily for commercial purposes (e.g. land surrounding principal home used as an orchard, even if accessed for other reasons)? What is the value of the portion of the land (up to two hectares) surrounding your principal home that is used primarily for commercial purposes? Is the property larger than 2 hectares (5 acres)? What is the estimate of the value of the home and surrounding 2 hectares (5 acres)? Does the property have more than one title document? Go to 19 Go to next question 19 Please read this before answering the following question. Are you (and/or your partner) over age pension age and receiving or claiming Age Pension, Carer Payment, Pension Bonus Bereavement Payment or Department of Veterans Affairs Age Service Pension? Go to 27 Go to next question Has the property been your principal home for 20 years or more continuously? Go to 27 Attach a copy of each title deed. From 1 July 2017, the qualifying age for Age Pension will increase from 65 years to 65 years and 6 months. The qualifying age will then rise by 6 months every 2 years, reaching 67 years by 1 July See table below. Date of birth Qualifying age at 1 July 1952 to 31 December years and 6 months 1 January 1954 to 30 June years 1 July 1955 to 31 December years and 6 months From 1 January years 20 Please read this before answering the following question. This question relates to the person who is age pension age and is receiving or claiming Age Pension, Carer Payment, or Department of Veterans Affairs Age Service Pension. te: For Pension Bonus Bereavement Payment this person may also include your late partner. Attach documents to provide evidence of the property having been your principal home for 20 years or more continuously. Go to next question 4 of 8

5 21 How do you (and/or your partner) currently use the property? Tick ALL that apply Do not currently make any use of the property Primary production Rural residential only Leased Other commercial or business use (e.g. commercial kennels) Hobby farm Other Give details below 26 Have 2 or more titles been amalgamated after 9 May 2006? int 27 Who owns the property? Your partner Private Company You Percentage owned Percentage owned Private Trust Percentage owned Percentage owned Other Give details below Name of person/entity 22 Does a family member use the property to support themselves? Go to next question Describe how they use the property to support themselves Percentage owned 28 Please describe all buildings on the property 1 What is the floor area in sq. metres (approx.)? How old is the building? 23 Is there any potential commercial use of the property (e.g. subdividing, agistment, hobby farming)? Describe the potential commercial use Type of construction Exterior (e.g. brick, timber) Interior (e.g. plaster, not lined) Roof (e.g. iron, tiles) 24 Are there any reasons that prevent you (and/or your partner) from using the property to produce an income? General condition Go to 27 Go to next question Number of flats/units (if applicable) 25 Explain why your property is not being used to produce an income? Tick ALL that apply Rural residential block Land is not viable for commercial or agricultural use Caring responsibilities Health reasons Zoning restrictions Environmental restrictions Other Give details below For residential building, number of bedrooms Number of other rooms (excluding laundry, bathroom, toilet) If you have more than 1 building on this property, attach a separate sheet with details. 5 of 8

6 29 Please read this before answering the following question. Only answer this question if this property is not your principal home. Household contents and personal effects. The current market value of the household contents and personal effects is what you would get if you sold it. It is not the replacement or insured value. Include: all furniture (including soft furnishings such as curtains), antiques and works of art electrical appliances such as televisions and fridges. What is your estimate of the current market value of the household contents you (and/or your partner) own in the property? Current market value 30 Is the property mortgaged or encumbered? Your share Go to 33 Amount owed Partner s share Attach the mortgage or loan agreement and the latest statement of your loan account. 31 Has another property (including your principal home) been used to secure this mortgage? Give details below Address of the other property used to secure the loan. Estimated market value Postcode 33 Do you (and/or your partner) receive any rental income from the lease of the property? Give details below 34 Gross amount of rent received (before tax and other deductions) per week Attach a copy of your last income tax return, rental profit/loss statement and depreciation schedule. Is the property only rented during holidays? Number of weeks per year 35 Do you (and/or your partner) receive any non-rental income from the property? Give details below Source of income (e.g. hobby farming, agistment) Gross amount received (before tax) per week Attach a copy of your last personal and business income tax returns and financial statements. 36 Are there any circumstances affecting the value of the property? This may include details such as: no water on property for grazing livestock, lack of adequate fencing, hills, rocky ground, natural bushland, unusual title. Go to next question Give details below If you (and/or your partner) have more than 1 property used as security, attach a separate sheet with details. 32 Give details of the loan How much do you (and/or your partner) owe? Interest rate per annum 37 If the property is hard to locate, please give full directions or provide a map. For what purpose were the funds borrowed? If you (and/or your partner) have more than 1 loan, attach a separate sheet with details. 6 of 8

7 Authority to inspect the property Purpose of this authority To enable us to correctly assess your entitlement, it may be necessary for a valuation of the property to be completed. In order to continue paying your correct entitlement, we may arrange to have the property professionally valued from time to time, at no cost to you. Information about having a valuation Why is a valuation required? The social security law requires that the value of assets (e.g. property, shares in a company, units in a trust) is included when calculating the amount of pension, benefit or allowance payable. How is the value of a property decided? The value of real estate is its current market value, less any allowable debts on the property. The current market value is the price the owner could expect to receive if the property was sold. Through regular updates using relevant market data the Department of Human Services will maintain the value of the property. What happens if there is no permission to inspect the property? If the value of the property is likely to affect a person s entitlement to social security payments or the rate of payment, but no permission to inspect the property is provided, the person s payment may not be granted or payment may be stopped. What if you are not satisfied with the valuation? If you are unhappy with a valuation, you should contact us. We will check the details, explain the decision, and if necessary arrange a further valuation. This gives you a chance to correct misunderstandings or present new information. If you disagree with the decision and would like the decision to be reviewed, we will forward the matter to a review officer. For more information about your review and appeal rights, or to request a review of a decision, go to our website or call us on or visit one of our Service Centres. 38 IMPORTANT INFORMATION 39 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 atwww. humanservices.gov.au/privacy or by requesting a copy from the department. Authority to inspect the property I hereby authorise a licenced valuer to enter and inspect the property for the purposes of a valuation in relation to the Social Security (Administration) Act I understand that if the property to be inspected is not occupied by me, it is my responsibility to give the actual occupant reasonable notice, or such notice as is required by agreement, of the inspection. This authorisation does not permit the valuer to enter my home, or any dwelling I may own, during the inspection, unless invited to do so. A similar condition applies to the home of any tenant involved. I further understand that the Department of Human Services or its representative will contact me, or the person noted below, to arrange a mutually convenient time for any inspection of the property. Your full name Address of property Postcode Person to be contacted by the valuer Person s daytime phone number ( ) Your signature Date Your partner s signature Date 7 of 8 Continued over the page

8 40 Which of the following forms, documents and other attachments are you (and/or your partner) providing with this form? If you are not sure, check the question to see if you should attach the documents. Real estate details form (Mod R) for each property you own (required for question 5) Copy of the latest council rate/valuation notice (If required for question 9) 42 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 make sure I receive the correct entitlement. Documents to show details of each water allocation (If you answered at question 11) Your signature Copy of the title deed for each parcel of land (If required at question 18) Documents to provide evidence of the property having been your principal home for 20 years or more continuously (If you answered at question 20) Date Your mortgage or loan agreement and the latest statement of your loan account for each property used as security (If you answered for questions 30) Your partner s signature Copy of the last income tax return, rental profit/loss statement and depreciation schedule for the rental property (If you answered at question 33) Copy of your last personal and business income tax returns and financial statements (If you answered at question 35) Date 41 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 atwww. humanservices.gov.au/privacy or by requesting a copy from the department. 8 of 8