Forms Centrelink Mod R Form – Fill Out and Use This PDF

Enter Your Customer Reference Number.

Enter Your family name, First given name and Second given name.

Enter Your date of birth.

Is the property fully owned by a private company and/or private trust that you are involved in? If Yes, do not complete this form. If No, go to next question.

How many properties in Australia and/or outside Australia do you (and/or your partner) own or have an interest in? You will need to complete and return a separate Real estate details (Mod R) form for each property you own if you have not already done so.

Enter the Address of the property, the Postcode and the Country (if not in Australia).

What type of property is this? Vacant land, Bush block, Home office/business, House, Self contained flat (part of or attached to a residence), Units/flats/town house, Retail premises, Commercial premises, Industrial premises, Farm (or hobby farm), Market garden, Residential block larger than 2 hectares (5 acres), or Other (give details).

What is the legal description of the property (for example, lot, section, parish; this may appear on the rates notice)? If the property is made up of more than 1 title, provide details for each separate title. Provide a copy of the latest council rate/valuation notice.

What is the estimate of the current market value of the property, including land, buildings and water assets (for example, water rights, allocations or licences)? You do not need to have the property professionally valued. Provide a copy of the water rights, allocation or licence documents, if applicable.

Only answer this question if this property is not your home property. What is your estimate of the current market value of the household contents you (and/or your partner) own in the property?

Do you (and/or your partner) live on the property?

Are you (and/or your partner) using any rooms or buildings of your home property only for business (for example, rooms used exclusively for a bed and breakfast business)?

What is the value of the rooms or buildings of your home property used only for business? For example, the percentage of the total value of the home being used for business purposes.

Is the property larger than 2 hectares (5 acres)?

Does the property have more than 1 title document?

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 (for example, commercial kennels), Hobby farm.

Who owns the property? Enter the Percentage owned for You and for Your partner. For Other, enter the Name of person/entity and the Percentage owned.

Property financial details. How did this property come into your (and/or your partner's) ownership? Purchased, with the Purchase price; Inherited/Gifted; or Other (give details).

When did this property come into your (and/or your partner's) ownership (the date of settlement)?

Complete ONE of these measurements only: Area in hectares, Area in acres, Area in square metres, or Dimensions.

Is the property mortgaged or encumbered?

Do you (and/or your partner) receive any rental income from the lease of the property? Enter the Gross amount of rent received (before tax and other deductions), $ per week.

How many weeks per year is the property rented?

Authority to inspect the property: Do you authorise a licenced valuer to enter and inspect the property for the purposes of a valuation in relation to the Social Security (Administration) Act 1999. 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.

Person to be contacted by the valuer: enter the Person's daytime phone number. If the property is hard to locate, give full directions or provide a map.

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, payment may be reduced or payment may be stopped.

Checklist: Which of the following forms and/or documents are you (and/or your partner) providing with this form? Tick all that apply: Real estate details (Mod R) form for each property you own (if required for question 5); Copy of the latest council rate/valuation notice (required for question 8).

Declaration: "I declare that the information I have provided in this form is complete and correct. Centrelink can make relevant enquiries to make sure I receive the correct entitlement."

Giving false or misleading information is a serious offence.

You sign on Your signature line, and your partner signs on Your partner's signature line; enter the Date.

If you are making a claim, you must return this form and all other supporting documents at the same time you lodge your claim form. If you do not return all documents, your claim may not be accepted. The only exception will be if you are waiting for medical evidence or other documents from a third party.

Do not complete this form if the property is fully owned by a private trust and/or private company, and you are involved with the private trust and/or private company. You must complete a Private Company (Mod PC) form and/or Private Trust (Mod PT) form for each property if you have not done so already.