Get AU CS4645 2021-2024

Statement of Financial Details to make a payment arrangement When to use this form Help in other languages This form requests a complete statement of your financial details so that we can determine a payment arrangement for you to pay your overdue child support as soon as possible. It is important that you provide full details of your income expenses assets and liabilities to help us decide the most appropriate payment arrangement for you. English If you do not speak English and need help from us call the Translating and Interpreting Service TIS on 131 450. At the end of this form you will be asked to offer a payment arrangement. We will then decide if this is suitable based on your circumstances. If your financial circumstances change after you complete this form you should notify us. We can then decide if we need to review this arrangement. If you make a suitable payment arrangement we may be able to reduce any late payment penalties that are currently payable. This form is available for printing online at humanservices.gov*au /forms You can provide this financial information over the phone. Call 131 272 Monday to Friday between 8.30 am and 4.45 pm* Note call charges apply - calls from mobile phones may be charged at a higher rate. Filling in this form Please use black or blue pen Print using BLOCK LETTERS Tick the appropriate box where applicable Sign the form Attach copies of supporting documentation where instructed* Korean Returning this form Send the completed form to The Department of Human Services GPO Box 9815 MELBOURNE VIC 3001 or Fax 1300 309 949 Form Contents PART A Your personal details PART B Your employment details PART C Your income details PART D Your expenditure details PART E Your assets and liabilities PART F Your payment offer PART G Your declaration 4645.1205 1 of 12 PART A YOUR PERSONAL DETAILS Privacy notice Privacy and your personal information Centrelink Medicare Australia Child Support and CRS Australia are services within the Australian Government Department of Human Services Human Services . Your personal information is protected by law including the Privacy Act 1988. Your information is collected for Social Security Family Assistance Medicare Child Support and CRS purposes. This information may be required by the powers provided within each services legislation or voluntarily given by you when you apply for services or payments. 1 What is your Child Support Reference Number 2 Your name Mr Mrs Miss Ms Other Family name Your information will be used for the assessment and administration of payments and services. Your information may also be used within Human Services where you have provided consent or it is required or authorised by law. Human Services may disclose your information to Commonwealth departments other persons bodies or agencies ONLY where you have provided consent or it is required or authorised by law. You can get more information about privacy by going to our website humanservices.gov*au/privacy or requesting a copy of the full privacy policy at one of our Service Centres First given name Second given name s 3 Date of birth / What if I have a complaint Step One 4 Your postal address Contact us and speak to a Customer Service Officer who will try to solve the problem* Step Two If you are not satisfied with the outcome ask to speak to their manager. Step Three 5 Your contact details If you are still not satisfied call our Complaints Service on 132 919 and speak to a Complaints Officer. Home phone number If you feel that we have been unable to successfully resolve your complaint you can escalate your concerns by contacting the Commonwealth Ombudsman* Work phone number How can I report suspected fraud If you have information about someone who is misusing government services please phone the Australian Government Services Tip-off Line on 131 524. Mobile phone number The tip-off line allows you to confidentially report fraud against Email 6 Do you have dependent children living with you A dependent child for child support purposes is a child you have a legal duty to maintain* This can be either a biological or an adopted child. No Yes 2 of 12 o to next question G Give details in the next column 7 Do you have a spouse or partner living with you to 9 Go Give details below 8 Does he or she work Yes Part time Yes Full time 9 Have you attempted to borrow money for the purpose of paying your outstanding child support Go to 11 10 Who did you approach on what date and what was the result You may tick more than one option if applicable. a* Financial institution Date Result b. c* Date Personal sources d. Please attach a separate sheet if you need to list additional Bank 3 of 12 PART B YOUR EMPLOYMENT DETAILS 13 Self-employed If you have or will receive income from a business including self-employment partnership company or trust this financial year give details below. 11 What are your employment details several sources and complete the section for each option you have ticked* E mployed on salary or wages L abour hire Not employed S Australian Business Number ABN Name of business partnership company or trust Industry type Are you a subcontractor or contractor 12 Employed on salary and wages Your occupation or trade Name of employer Estimated gross income this financial year Address of employer Estimated business expenses this financial year Name of client you contract to Estimated net profit or loss this financial year Employer s phone number Employer Australian Business Number ABN you are self-employed or involved in a company If partnership or trust please attach the most current copy of the following documentation Employer s business/trading name Balance sheet Statement of financial position Profit and loss Statement of financial performance Depreciation schedule Trust deed Partnership agreement Business bank statements including loans and credit cards for the last 6 months Alternatively you may provide us with your accountant s contact details in the next column and we will request these documents directly. If you have more than 1 employer attach a separate sheet with details. Note You should contact your accountant beforehand to determine if they will charge you a fee. If you need your accountant to provide documents and/or information we will not reimburse fees charged by the accountant. 4 of 12 Accountant s details Name of accountant Do you receive a government payment ype of payment e*g* Newstart Family T Tax Benefit etc* Accountant s postal address Amount Payment frequency Name of company Type of income Organisation details if applicable Employer s industry Date commenced Gross income Date last paid This amount covers the period to Start date of contract Go to PART C when you have completed your employment details. End date of contract If you are employed by multiple labour hire companies attach a separate sheet with details. 5 of 12 PART C YOUR INCOME DETAILS Income is not restricted to taxable income and includes any money received earned or derived for personal use or benefit or any periodic payment by way of gift or allowance. Salary sacrifice / salary packaging includes any benefit received as part of earned income but not as a wage or salary e*g* novated lease use of a car as part of a salary package. Government payments include any pensions benefits Centrelink payments and allowances and payments from the Department of Veterans Affairs e*g* Family Tax Benefit. Interest and dividends include any income you receive from cash deposits shares managed investments and forestry managed investment schemes. Foreign income includes any income you receive from outside Australia* Regular payments include compensation and rehabilitation payments allowances or gifts. Other income includes any other income you receive that is not listed below e*g* personal income derived from self employment royalties pocket money etc* Complete either the gross or net amount for each item that applies to you and if possible calculate totals. You can also add new items. If an income type listed below does not apply to you leave the space blank. Please indicate how each income item you receive is shown A Weekly B Fortnightly C Monthly D Annually Income type Gross Net after tax Salary or wage including allowances Supernannuation pension Child/spousal maintenance received Rental income Trust distribution Partnership distribution D C Commissions B A TOTAL CURRENT INCOME 18 If you expect to receive any of the following lump sum payments in the next 12 months give details below. Termination payments Redundancy payments Capital gains Lump sum superannuation payments Compensation or rehabilitation payments TOTAL FUTURE EXPECTED INCOME 6 of 12 Payment date PART D YOUR EXPENDITURE DETAILS 19 What are your current personal expenses Please provide details of all your personal expenses. Do not include expenses that are related to the operation of a business. If your expenses are shared only provide the portion of those expenses that are incurred by you e*g* you contribute 50 towards the costs of electricity. The electricity bill averages 100 per month so your share will be 50. Where possible calculate sub-totals and totals. You can also add new expense items. If an expense item listed does not apply to you leave the space blank. Tick the option A B C or D for how each expense item is shown Household expenses Rent Repairs Gas Electricity Water Phone Rates Body corporate fees Internet Cable/TV Furniture Appliances Groceries Gardening Sub total Medical expenses Doctor Medicines Dentist Education expenses School fees University/TAFE fees Tuition Books and uniforms Camps/excursions Transport expenses Car registration Fuel Repairs/maintenance Parking Public transport A Weekly B Fortnightly C Monthly D Annually 7 of 12 PART D cont. YOUR EXPENDITURE DETAILS Debt repayments Mortgage family home Rental property loan s Car lease/loan s Investment loan s HECS/HELP payments Credit card s Personal loan s Department store card s Lay-by s Overdraft Taxation debt Centrelink debt Savings Regular savings Regular investments Insurance Home and contents Car Health Income protection Life Other expenses Child care Child support payments Gifts Donations Hobbies and sports Subscriptions Newspapers/ magazines Movies and DVDs Restaurants/ takeaway Alcohol and cigarettes Pet costs Personal Expenses Hair and beauty Clothes and shoes TOTAL CURRENT EXPENSES 8 of 12 21 Do you own partly own or have a financial interest in any PART E YOUR ASSETS LIABILITIES motor vehicles motorcycles boats trailers caravans or motor homes property assets 1 ype of asset e*g* car 1 Type of property e*g* family home Make e*g* Holden Address of property Model e*g* Astra Current market value Amount owed Year Minimum monthly repayment Joint ownership Your share Model e*g* VTR 250 sheet with details. 9 of 12 22 Do you have any cash assets shares bonds or other investments 1 Type of account e*g* savings account 1 Type of investment Name of financial institution/bank Branch number BSB Current amount invested Currency if not AUD Account number Balance separate sheet with details. 24 Do you have a life insurance policy that includes a savings or investment component N o 1 Name of insurance company Policy number Surrender value PART F YOUR PAYMENT OFFER Please read this section before making your payment offer. Your payment offer is the minimum amount you offer to pay. You can make an offer for a payment for the full debt amount a regular amount or a combination of a lump sum and a regular amount. reasonable amount. 1 Name of institution/ company Non preserved amount You should commence payment immediately and continue to make payments while your proposal is being considered* If your proposal is accepted we will notify you in writing and you must meet the terms of the arrangement and make each payment in full by the due date. If you do not make a payment offer or commence making payments immediately we will take action to collect the amount outstanding. You can pay above the agreed amount. If your current child support is being deducted from your salary the additional amount agreed to will be deducted from your salary. We will review your payment arrangement during its term to see whether your financial situation has changed and the payment offer is still appropriate. 28 Do you agree to make a lump sum payment 26 What is your estimate of the current market value of your Payment amount Date payment will be made on household contents and personal effects 27 Have you sold or given away any of your assets to friends relatives or other people in the past 12 months Date your regular payment will start from PART G YOUR DECLARATION 30 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. t paying my ongoing child support amount. Your signature IMPORTANT You should retain a copy of this form for your records.