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

When to use this form

Online services

Help filling in this form

This form is used to work out your share of a property’s asset value and income.

Home property

Use this form if:

•your home property is:

–more than 2 hectares (5 acres)

–on more than 1 title, or

–used for business purposes

•you are in a care situation and have been absent from your home property for 2 years or more

•you entered a care situation on or after 1 January 2017 and you are renting out your former home

•you have been temporarily absent from your home property for more than 12 months.

Other property

Use this form if you own any real estate not listed above in Australia or outside Australia.

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 form (Mod PC) and/or Private Trust form (Mod PT) for each property if you have not done so already.

Completing this form online is faster and easier.

You can update your real estate information using your Centrelink online account through myGov. For help, go to humanservices.gov.au/onlineguides

If you do not have a myGov account, you can create one at my.gov.au and link it to your Centrelink online account.

For more information, go to humanservices.gov.au/realestateincome or humanservices.gov.au/realestateassets

If you need to call us, go to humanservices.gov.au/phoneus

We can translate documents you need for your claim or payments for free.

To speak to us in other languages, call 131 202.

Note: Call charges may apply.

If you have a hearing or speech impairment, you can contact the TTY service Freecall™ 1800 810 586. A TTY phone is required to use this service.

Authority to inspect the property

Purpose of this authority

To enable the Australian Government Department of Human Services 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?

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, beneit 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 we 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 oficer.

Filling in this form

• Print in BLOCK LETTERS.

• 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.

1Is the property fully owned by a private company and/or private trust that you are involved in?

No	Go to next question
Yes	Do not complete this form. You must complete
	a Private Company form (Mod PC) and/or
	Private Trust form (Mod PT) for each property if
	you have not already done so.
	If you do not have these forms, go to
	humanservices.gov.au/forms

About YOU

2Your Centrelink Reference Number

3Your family name

First given name

Second given name

4Your date of birth

//

Mod(R).1801

About YOUR PROPERTY

5How 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 attach a separate

Real estate details form (Mod R) for each property you own if you have not already done so. If you do not have this form, go to

humanservices.gov.au/forms

6Address of the property

Postcode

Country (if not in Australia)

7What type of property is this?

Vacant land Bush block Home ofice/business House

Self contained lat (part of or attached to a residence)

Units/lats/town house Retail premises Commercial premises Industrial premises Farm (or hobby farm) Market garden

Residential block larger than 2 hectares (5 acres)

Other		Give details below

CLK0MOD(R) 1801

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8What is the legal description of the property (e.g. lot, section, parish, etc. – this may appear on the rates notice)?

Note: If the property is made up of more than 1 title, provide details for each separate title.

Attach a copy of the latest council rate/valuation notice.

9What is the estimate of the current market value of the property, including land, buildings and water assets (e.g. water rights, allocations or licences)?

You do not need to have the property professionally valued. We may have the property valued at no cost to you.

$

Attach a copy of the water rights, allocation or licence documents, if applicable.

10Please read this before answering the following question.

Only answer this question if this property is NOT your home property.

The current market value of the household contents 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, and

•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					Amount owed
	$				$
	Your share		%		Partner’s share	%

11Do you (and/or your partner) live on the property?

No	Go to 28
Yes	Go to next question

12Are you (and/or your partner) using any rooms or buildings of your home property only for business (e.g. rooms used exclusively for a bed and breakfast business)?

No	Go to 14
Yes	Go to next question

13What 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.

$

14Is any portion of the land surrounding your home property used primarily for business purposes (e.g. land surrounding your home property used as an orchard, even if accessed for other reasons)?

No	Go to 16
Yes	Go to next question

15What is the value of the portion of the land (up to 2 hectares or 5 acres) surrounding your home property that is used primarily for business purposes?

$

16Is the property larger than 2 hectares (5 acres)?

No	Go to 18
Yes	Go to next question

17What is the estimate of the value of the home and surrounding 2 hectares (5 acres)?

$

18Does the property have more than 1 title document?

No	Go to 20
Yes	Go to next question

19What is the estimate of the value of the home and surrounding title?

$

Provide the legal description and area of the title on which the home sits.

Attach a copy of each title deed.

20Please read this before answering the following question.

From 1 July 2017, the qualifying age for Age Pension increased from 65 years to 65 years and 6 months.

The qualifying age rises by 6 months every 2 years, reaching 67 years by 1 July 2023.

See table below.

Date of birth		Qualifying age at
1	July 1952 to 31 December 1953	65 years and 6 months
1	January 1954 to 30 June 1955	66 years
1	July 1955 to 31 December 1956	66 years and 6 months
From 1 January 1957		67 years

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?

No	Go to 28
Yes	Go to next question

21Please 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.

Note: For Pension Bonus Bereavement Payment this person may also include your late partner.

22How 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

23Does any person in your family use the property to support themselves?

No	Go to next question
Yes	Describe how they use the property to support
	themselves

24Is there any potential commercial use of the property (e.g. subdividing, agistment, hobby farming)?

No		Go to next question
Yes		Describe the potential commercial use

25Are there any reasons that stop you (and/or your partner) from using the property to produce an income?

No	Go to 28
Yes	Go to next question

26Why is your property 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

27Have 2 or more titles been amalgamated since 9 May 2006? No

Yes

28Who owns the property?

	You		Percentage owned	%
	Your partner		Percentage owned
				%
	Other		Give details below
	Name of person/entity
	Percentage owned
	%

29Did you (and/or your partner) purchase this property?

No Go to next question

Yes Give details below

Date of purchase

/ /

Purchase price

$

30What is the area or the dimensions of the property? Complete ONE of these measurements only.

	Area in hectares
OR	Area in acres
OR Area in square metres
OR	Dimensions			X

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.

31Describe all buildings on the property This will assist us to value the property.

1

What is the approximate loor area		How old is the
in square metres?		building?
Type of construction
	Exterior (e.g. brick, timber)
	Interior (e.g. plaster, not lined)
	Roof (e.g. metal, tiles)
General condition (e.g. fair, good, poor)

Total number of lats/units in complex (if applicable)

For residential building, number of bedrooms

Number of other rooms (excluding laundry, bathroom, toilet)

If you (and/or your partner) have more than 1 building on this property, attach a separate sheet with details.

Property FINANCIAL DETAILS

32Is the property mortgaged or encumbered?

No	Go to 35
Yes	Attach the:

•mortgage or loan agreement(s) showing which assets or properties are held as security against the loan (if applicable), and

•latest statement of each loan account.

33Has another property (including your home property) been used to secure this mortgage?

No	Go to next question
Yes	Give details below

Address of the other property used to secure the loan.

Postcode

Estimated market value

$

If you (and/or your partner) have more than 1 property used as security, attach a separate sheet with details.

34Give details of the loan

How much do you (and/or your partner) owe?

$

Interest rate per annum

%

Purpose of the loan

If you (and/or your partner) have more than 1 loan, attach a separate sheet with details.

35Do you (and/or your partner) receive any rental income from the lease of the property?

No	Go to 37
Yes	Give details below

Gross amount of rent received (before tax and other deductions)

$	per week

Attach a copy of your (and/or your partner’s):

•last Income Tax Return

•rental proit/loss statement, and

•Depreciation Schedule.

36How many weeks per year is the property rented? weeks per year

37Do you (and/or your partner) receive any non-rental income from the property?

No	Go to next question
Yes	Give details below

Source of income (e.g. hobby farming, agistment)

Gross amount received (before tax)

$	per week

Attach a copy of your (and/or your partner’s) last personal and business Income Tax Return and inancial statements.

38Are 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.

No	Go to next question
Yes	Give details below

AUTHORITY TO INSPECT the property

39Refer to Authority to inspect the property in the Notes for more information.

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 1999.

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.

No	Go to 43
Yes	Go to next question

40Are you the person who can be contacted by the valuer?

No	Go to next question
Yes	Go to 42

41Person to be contacted by the valuer

Person’s daytime phone number

()

42If the property is hard to locate, give full directions or provide a map.

Checklist

43Which of the following forms, documents and other attachments are you (and/or your partner) providing with this form?

Important Note: 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.

If you are not sure, check the question to see if you should attach the documents.

Tick ALL that apply

Real estate details form (Mod R) for each property you own

(if required for question 5)

Copy of the latest council rate/valuation notice (required for question 8)

Documents to show details of each water asset (if required for question 9)

Copy of each title deed

(required for question 19)

Documents to provide evidence of the property having been your home property for 20 years or more continuously

(if you answered Yes at question 21)

Your mortgage or loan agreement(s) showing which assets or properties are held as security against the loan and latest statement of each loan account

(if you answered Yes at question 32)

Copy of the last Income Tax Return, rental proit/loss statement and Depreciation Schedule for the rental property

(if you answered Yes at question 35)

Copy of your last personal and business Income Tax Return and inancial statements

(if you answered Yes at question 37)

Mod(R).1801

Obligations

44You need to read this

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 where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations).

You can get more information about the way in which the department will manage your personal information, including our privacy policy, at humanservices.gov.au/privacy

45Statement

I declare that:

•the information I have provided in this form is complete and correct.

I understand that:

•giving false or misleading information is a serious offence.

•if submitting this document as part of a claim, the claim may not be accepted unless supporting documents are lodged at the same time as the claim. The only exception will be if I am waiting for medical evidence or other documents from

a third party.

•the Australian Government Department of Human Services can make relevant enquiries to make sure I receive the correct entitlement.

Your signature

Date

/ /

Your partner’s signature

Date

/ /

Returning your form

You can return this form and any supporting documents:

•online using your Centrelink online account. For more information, go to humanservices.gov.au/submitdocumentsonline

•in person at one of our service centres, if you are unable to use your Centrelink online account.

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