Instructions

Separation details

This form lets us know you have separated from

your partner.

When to use this form Use this form if you currently receive a payment from us and have separated
from your partner.
If your partner has passed away, you do NOT need to fill in this form. You can
call us on 132 300 or fill in an Advice of death form (SA116A).
Go to humanservices.gov.au/bereavement
www.

If you currently receive Parenting Payment or Newstart and you have a

dependent child or children, you are also required to complete the Verification
of Relationship Status form (SC321).
To obtain a copy of this form, go to humanservices.gov.au/forms
www.

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.

Online services Upload documents

You can complete this form on your computer, print and sign it, and upload it in
your Centrelink online account.

Select Upload Documents, choose ‘Centrelink form code’ and type ‘MOD S’.
Go to humanservices.gov.au/submitdocumentsonline
www.

Help filling in this form

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
on Freecall™ 1800 810 586. A TTY phone is required to use this service.

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Support for Separation is a time of change and it is important to get help if you need it. If you
separated people require support, there are a number of groups, websites, publications and support
services available.
Go to humanservices.gov.au/separationsupport
www.

If you are in, have left, or are preparing to leave a family and domestic violence
situation, or are concerned about your safety, we can provide support.

Relationships and Our social workers can help with short term counselling and information and can
safety concerns tell you where you can get other support and services, if needed.
If you wish to speak to a social worker, call us on 132 850 or visit one of our
service centres and ask to speak to a social worker.
For more information, go to humanservices.gov.au/domesticviolence
www.

Your relationship For more information on how we assess your relationship status, go to www.

status humanservices.gov.au/moc

Children from a To get more than the base rate of Family Tax Benefit Part A, you will need to take
previous relationship reasonable steps to obtain child support from the other parent.
If there is any reason that makes it difficult for you to apply for child support,
it is important that you contact us to talk about your situation. There may be other
options available to you.

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 Separation details

Filling in this form About YOUR EX-PARTNER

• Please use black or blue pen.
• Print in BLOCK LETTERS. 6 Your ex-partner’s family name
• 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. First given name

Second given name

About YOU

1 Your Centrelink Reference Number

You can find this on letters we have sent you, your Health
Care Card or Concession Card. 7 Do you know if your ex-partner has been known by any other
name(s)?
For example: Name at birth, name before marriage, previous
married name, Aboriginal or tribal name, alias, adoptive
name, foster name.
2 Your family name
No Go to next question
Yes Give details below
First given name
Other name(s)

Second given name

3 Your date of birth If you need more space attach a separate sheet with details.
/ /

8 Do you live in the same home as your ex-partner?

4 Has your phone number changed since you last told us? No Go to 10
No Go to next question Yes Go to next question
Yes Phone number
( ) 9 Are you concerned about your safety if forms are issued to your
ex-partner?
No Both you and your ex-partner each need to
5 Has your address or accommodation details changed since you complete and attach a separate Relationship
last told us? Details – Separated under one roof form
No Go to next question (SS293).
If you do not have this form, go to
Yes You will need to complete and attach an
www.

humanservices.gov.au/forms
Accommodation Details form (Mod AC).
Go to 11
If you do not have this form, go to
www.

humanservices.gov.au/forms Yes Only you need to complete and attach a

Go to next question Relationship Details – Separated under one
roof form (SS293).
If you do not have this form, go to
www.

humanservices.gov.au/forms
Go to 11

CLK0Mod(S) 1809

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10 Your ex-partner’s current address (if known) Who can VERIFY YOUR SEPARATION

14 Are you getting:

• Parenting Payment Partnered and are transferring to
Parenting Payment Single, or
Postcode
• Newstart Allowance at the partnered rate and you have a
dependent child or children in your care?
About YOUR RELATIONSHIP No Go to next question
Yes You will need to complete and attach a
11 Tick ONE of the boxes below to tell us about your relationship Verification of Relationship Status form
status right now. (SC321). If you do not have this form, go to www.

humanservices.gov.au/forms
Separated
Go to 16
(previously lived with a partner, including in a
marriage, registered or de facto relationship)
Divorced
15 We need the names and contact details of two people who
know about your separation or divorce.
12 When did you separate from your partner? They must NOT be closely related to you or your ex-partner.
You need to fill in all parts of this question: day, month 1 Name
and year. If you do not, it will take more time to update
your details.
Address
/ /

13 Do you think that you and your ex-partner will get back
together?
Postcode
No Go to next question
Phone number
Yes Give details below
( )
When will you get back together?
Relationship to you

How long have you known this person?

2 Name

Address

Postcode
Phone number
( )
Relationship to you

How long have you known this person?

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 About YOUR CHILDREN About your INCOME AND ASSETS

16 Do you have any children or students in your care 20 Have you received, or are you expecting to receive, any money
under 20 years of age? or property as a result of your separation or divorce?
No Go to 20 No Go to next question
Yes Go to next question Yes Give details below

17 You need to read this before filling in the next question.

To get more than the base rate of Family Tax Benefit Part A,
you will need to take reasonable steps to obtain child support
from the other parent. To make an application for child
support online, go to humanservices.gov.au/csandftba
www.

Do you get Family Tax Benefit for the child or children in your
care?
No You may be eligible for Family Tax Benefit.
For more information, go to www.

humanservices.gov.au/families
Go to next question

Yes We recommend providing a new income estimate

for Family Tax Benefit. You can update your
estimate online.
Go to humanservices.gov.au/families
www.

Go to next question

18 Do you get Parenting Payment for the child or children in your

care?
No For more information, go to www.

humanservices.gov.au/parentingpayment
Go to next question

Yes Go to next question

19 Will you share the care of any of the children or has the number
of children in your care changed since you separated or divorced?
No You will need to contact us if your care
arrangements change to update your details.
If you need more space, attach a separate sheet with details.
Go to next question

Yes You will need to complete and attach a Details 21 Has there been any other changes to your income and assets?
of your child’s care arrangement form
(FA012). If you do not have this form, go to
www.
No Go to next question
humanservices.gov.au/forms Yes You will need to complete and attach an Income
and Assets form (Mod iA).
If you do not have this form, go to
www.

humanservices.gov.au/forms

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 About YOUR PAYMENT Privacy notice

22 Where do you want your payment made? 23 You need to read this
Privacy and your personal information
Use the account details I have Go to next question
already given Your personal information is protected by law (including
the Privacy Act 1988) and is collected by the Australian
A different account Give details below Government Department of Human Services for the
assessment and administration of payments and services. This
The bank, building society or credit union account must be in information is required to process your application or claim.
your name. A joint account is acceptable. Your information may be used by the department, or given
Do NOT include an account used only for funding from the to other parties where you have agreed to that, or where it
National Disability Insurance Scheme. is required or authorised by law (including for the purpose of
research or conducting investigations).
1 Which payment would you like us to update? You can get more information about the way in which the
department will manage your personal information, including
Tick this box if you would like all your payments our privacy policy, at humanservices.gov.au/privacy
www.

to go into this account

OR
List the payment(s) to go into this account 24 Declaration
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.
Name of bank, building • if I get back together with my ex-partner, or become a
society or credit union member of a couple, I must tell the Australian Government
Department of Human Services immediately.
Branch number (BSB)
• the Australian Government Department of Human Services
Account number can make relevant enquiries to make sure I receive the
(this may not be your correct entitlement.
card number)
Account held in the name(s) of Your signature

On completion of this form,

please print and sign by hand

2 Which payment would you like us to update? Date

List the payment(s) to go into this account / /

Next steps
Name of bank, building
1 Check that you have answered all the questions that you
society or credit union
need to.
Branch number (BSB) 2 Attach all requested information and any additional
required forms.
Account number
(this may not be your 3 Check you have signed and dated this form.
card number)
Account held in the name(s) of
Returning your form
You can return this form and any supporting documents:
• online using your Centrelink online account.
For more information, go to www.

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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