156x Filetype PDF File size 0.16 MB Source: www.servicesaustralia.gov.au
Executor/Administrator Request for information (SS524) When to use this form Deceased person’s details Use this form to request information from Services Australia regarding a deceased person. 1 Customer Reference Number (if known) Information will only be disclosed to: • the executor as named in the Will • the Public Trustee 2 Mr Mrs Miss Ms Other and/or • a court, Family name • the administrator of the estate. If you are not one of the above, contact us. First given name What else will you need to provide Second given name You will need to provide proof you have the authority to act on the deceased person’s estate. For example: • a copy of the Will 3 Date of birth • letters of administration / / • a court order or similar legal document • a letter from the legal representative of the executor or 4 Permanent address before death administrator of the estate. Filling in this form • Use black or blue pen Postcode • Print in BLOCK LETTERS. 5 Date of death For more information / / Go to www.servicesaustralia.gov.au/bereavement or call us on 132 300 Monday to Friday, 8 am to 5 pm, Australian Eastern Standard Time. 6 Relationship status at time of death To speak to us in your language, call 131 202. Single Married Registered De facto Call charges may apply. Widowed Separated Divorced If you have a hearing or speech impairment, you can contact the Partner’s name (if applicable) TTY service Freecall™ 1800 810 586. A TTY phone is required to use this service. 7 Under what authority are you requesting this information? Information will only be released to you if you have the appropriate authority. Executor as named in the Will The administrator of the estate The Public Trustee A court order You will need to provide proof you have the authority to act on the deceased person’s estate. CLK0SS524 2105 SS524.2105 1 of 2 Authorised person’s details Privacy notice 8 Mr Mrs Miss Ms Other 13 You need to read this Family name Privacy and your personal information The privacy and security of your personal information is important to us, and is protected by law. We collect this First given name information to provide payments and services. We only share your information with other parties where you have agreed, or where the law allows or requires it. For more information, go to www.servicesaustralia.gov.au/privacy 9 Organisation name (if applicable) 14 Declaration 10 Postal address 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. Postcode Your full name 11 Daytime phone number Your signature Information to be requested from Services Australia 12 What information about the deceased person are you requesting? Date Select ALL that apply / / Whether the agency owes money to the estate, and if so, the amount Whether the deceased person owed money to the agency at the time of death, and if so, the amount Whether the agency will be making a claim against the Returning this form estate, and if so, the amount Check that all required questions are answered and that the form Whether there is an outstanding review of decision is signed and dated. A statement of payment for the current financial year Return this form: A statement of payment for the previous financial year • by fax to 1300 786 102. • by post to: Other (give details below) Services Australia PO Box 7800 Canberra BC ACT 2610 • in person at one of our service centres. SS524.2105 2 of 2
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