Youth Allowance or ABSTUDY

Unreasonable to live at home Statement by Young Person

Return this form to one of our Service Centres by at the following address / /

Postcode Name of young person claiming Unreasonable to live at home

Centrelink Reference Number

Purpose of this form

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.

For more information

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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Filling in this form

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.

Returning your form

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
www.

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
www.

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Your name Mr Mrs Miss Ms Other

Have you left your parent(s) home previously? No Yes

Go to next question
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 / / / / / / /

Second given name

/ Your date of birth / /

If you have left home on more than 4 occasions, attach a separate sheet with details.

Your Centrelink Reference Number (if known)

Your contact numbers Phone number ( ) No Yes

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

Go to next question

Is this a silent number? Mobile phone number

Go to 11
Give details below

Your current address

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10 Give the name of the refuge/hostel, or name(s) of people you live

with now. Postcode

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

11 How long do you expect to live in this arrangement?

Emergency/short term Long term Not sure

Go to next question Do not answer questions 7 to 33. Go to 34

12 Details of your parent, with whom you last lived.

Name

What date did you move out of your parent(s) home? / /

Address

Postcode Contact phone number Relationship to yourself: ( Mother ) Father Guardian

CLK0SY015 1312

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13 Your other parents details

Name

17 Is anyone other than your parent(s) responsible for looking after

you (e.g. a guardian)? Guardian means any other person whom you are substantially dependent on. No Yes Postcode

Address

Go to next question
Give details below

Persons name

Contact phone number Relationship to yourself:

( Mother

) Father Guardian

Their address

14 Do your parent(s) live together?

No Yes

Postcode Contact phone number ( )

Go to next question Go to 17

15 When last did you have contact with your other parent?
/ /

How long have they looked after you? (e.g. number of days/months/years)

16 Will your other parent allow you to live with them?

No Yes Give details below

18 Are you receiving support from your parent(s)/guardian(s) or any

other person (e.g. food, help paying bills, help paying rent, help paying school fees, receiving regular money)? No Yes

Go to next question
Give details below

19 Is there anyone else that can tell us about your family

circumstances (e.g. a counsellor, teacher, doctor, relative or family friend)? No Yes

Go to next question
Give details below

Persons name

Their address

Postcode Contact phone number ( )

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20 Please read this before answering the following question.

Permission to contact: We may need to talk to your parent(s)/guardian(s) and a third party to discuss your family situation. If you do not want this to happen, you will have to talk to us to discuss your reasons. Do you give permission for us to talk to: the person identified in question 12 the person identified in question 13 the person identified in question 17 the person identified in question 19 No No No No Yes Yes Yes Yes

22 How are you affected by the incident(s) and/or problem(s) that

made you leave home?

21 What incident(s) and/or problem(s) made you leave home?

Give details and examples below.

23 Have you and/or your parent(s)/guardian(s) tried to sort out your

differences (e.g. counselling, mediation or attempts by yourself or your parent(s)/guardian(s) to improve your relationship)? No Yes

Go to next question Go to 25

24 Why havent you and/or your parent(s)/guardian(s) tried to sort

out your differences?

Go to 26
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25 Give details of any people and/or organisations that you and/or

your parent(s)/guardian(s) have gone to for help to sort out your differences.

28 Will your parent(s)/guardian(s) allow you to return home to live?

No Yes

Go to next question Go to 30

1 Name of person or organisation

29 Give reasons why your parent(s)/guardian(s) will not allow you to

return home to live. Has going to this person or organisation helped improve your relationship?

No

Yes

2 Name of person or organisation

Has going to this person or organisation helped improve your relationship?

No

Yes

26 Has your relationship with your parent(s)/guardian(s) changed

since you left home? No Yes

Go to next question
Has your relationship improved or deteriorated? Improved Deteriorated

27 Have you had any contact with your parent(s)/guardian(s) since

you left home? No Yes

Go to 31

Go to next question
Give details below Include: type of contact (e.g. phone call, visit) how often contact has been made who initiated the contact.

30 Do any conditions apply if you return home to live with your

parent(s)/guardian(s)? No Yes

Go to next question
Give details below

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31 Do you want to return home to live with your parent(s)/guardian(s)?

No Yes Give comments below Note: If your parent(s)/guardian(s) do not live together, nominate which parent(s)/guardian(s) you would like to live with.

33 Do you need to change your bank account details?

No Yes

Go to next question
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

Go to next question
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 / /

If you need more space, attach a separate sheet with details.

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