Who should complete this application:

This form should be completed by or on behalf of dependants of a member or former member of the Australian Defence Force who had service on or after 1 July 2004 and:

• whose death is being claimed as related to that service; or
• who was entitled to maximum permanent impairment compensation under the MRCA immediately before his or her death; or
• who met the criteria for a Special Rate Disability Pension during some point in his or her life.
• It should also be completed by deceased’s LPR to claim funeral benefits.

Definition of dependant
A person who was, immediately before the death, in one of the following relationships with the deceased:

• spouse;
• either a same-sex or opposite-sex relationship with another person which is registered under a prescribed law of a State or Territory. For a list of those laws, please contact the Department of Veterans’ Affairs;
• either a same-sex or opposite-sex de facto relationship with the deceased that was not registered;
• parent, step-parent, father-in-law, mother-in-law, grandfather, grandmother, son, daughter, step-son, step-daughter, grandson, granddaughter, brother, sister, half-brother or half-sister of the deceased. These terms apply equally to heterosexual and same sex relationships. For example:

• the parents of the partner of a person in a same-sex relationship are included in the term ‘father-in-law’ and ‘mother-in-law’; and
• the son or daughter of the partner of a person in a same-sex relationship are also included in the term ‘son’ or ‘daughter’ of the person;

• where the deceased was a member of the Aboriginal race of Australia or a descendant of indigenous inhabitants of the Torres Strait Islands - a person who is or was recognised as the deceased's spouse by the custom prevailing in the tribe or group to which the deceased belonged;
• a person in relation to whom the deceased stood in the position of a parent or who stood in the position of a parent to the deceased.

who was

• wholly or partly dependent for economic support on the deceased at the date of the deceased’s death; or
• would have been wholly or partly dependent on the deceased but for an incapacity resulting from a defence-related injury or disease. A partner or an eligible young person (under 16 or between 16 and 25 and in full-time education and not full-time work) in one of the above-listed relationships with the deceased is automatically taken to have been wholly dependent for economic support on the deceased at the date of death if they:
• were, immediately before the death, living with the deceased; or
• would have been living with the deceased but for:

• a temporary absence of the partner, child or the deceased; or
• an absence of the partner, child or the deceased due to illness or infirmity.

This application asks about

• the dependant(s) personal details.
• details of the deceased member.

Completing this application
Not all questions in this form will apply to you. You will be able to skip questions which don’t apply.

If you do not have enough space to answer a question, use a separate piece of paper. The information you give should be as complete as possible so that your claim is not delayed. If you cannot answer any of the questions, fill in as much as you can and contact the Department of Veterans’ Affairs (DVA) for assistance.

If you are asked to provide copies of documents, you must provide certified copies or original documents which can be sighted and verified by a DVA officer.

Proof of identity
You will need to provide proof of your identity before the finalisation of your claim. DVA can provide you with information on what forms of identity you will need to provide. Otherwise Fact Sheet DVA06-Proving your identity to DVA is available on the DVA website.

Assistance from service and ex-service organisations You are strongly encouraged to seek assistance from a service or ex-service organisation of your choice in lodging this claim. Contact telephone numbers for these organisations can be found in the local telephone directories or by contacting the DVA office in your State.

Privacy Notice
The information provided on this form, and on any additional DVA forms you complete in relation to this claim, is required to assess your eligibility for benefits under the MRCA. Any information you provide on this form, or any other forms relevant to this claim, may be disclosed to the following agencies and bodies for their lawful purposes:

• the Department of Defence;
• Centrelink;
• the Australian Taxation Office;
• the legal representatives of the Department of Defence in relation to any Common Law (Third Party) damages action;
• State and Local Government Authorities to verify a dependant’s eligibility for rebates or concessions e.g. concessions relating to rates, electricity, transport, motor vehicles, ambulance; and
• doctors, hospitals and other health care professionals who provided the deceased member with treatment or who are requested to assist in the investigation of this claim.

Information provided may also be made available to Centrelink for the purpose of assisting State and Local Government authorities to verify a dependant’s eligibility for rebates or concessions e.g. concessions relating to rates, electricity, transport, motor vehicles, ambulance.

You must tell DVA if any of the details you provide in this application change.

If you need more information please contact DVA:
National toll Free Number
1800 838 372

Internet

http://www.dva.gov.au/benefitsAndServices/Pages/VEAbenefits.aspx

Addresses
by Mail:
Department of Veterans' Affairs
GPO Box 9998
BRISBANE QLD 4001

In person
Contact 1800 838 372 for the address of the nearest VAN office

Complete this application if you are claiming:

• acceptance of liability for injury or disease arising from service on or after 1 July 2004
• reassessment of compensation payable under the Military Rehabilitation and Compensation Act 2004 (MRCA)

This application asks about

• your personal details
• your injury or disease.

Proof of identity
You will need to provide proof of your identity before the finalisation of your claim if you have not provided this before. The Department of Veterans’ Affairs (DVA) will provide you with information on what forms of identity you will need to provide.

Assistance from service and ex-service organisations
You are strongly encouraged to seek assistance from a service or ex-service organisation of your choice in lodging this claim. Contact telephone numbers for these organisations can be found in local telephone directories or by contacting the DVA office in your State.

Assistance from Veteran' Affairs
DVA staff can also help you to complete this application.

The basis for decisions
the decisions on whether your injury or disease is service-related is based on up-to-date medical and scientific evidence. The information is detailed in the Repatriation Medical Authority’s Statements of Principles.
If your claim is for a condition not included in the Statements of Principles, it will be determined based on the best scientific and medical evidence available.

Privacy Notice
The information provided on this application, and on any additional DVA forms you complete in relation to this claim, is required to assess your eligibility for benefits under one or more of the following applicable Acts: Veterans’ entitlements Act 1986 (VEA), Safety, Rehabilitation and Compensation Act 1988 (SCRA) and MRCA. If the information you provide is used to assess your eligibility under one ACT, it will not be used for the purpose of another Act unless authorised by law or you give a separate consent. Any information you provide in this application, or any other form relevant to this claim, may be disclosed to the following agencies and bodies for their lawful purposes:

• the Department of Defence;
• Centrelink;
• the Australian Taxation Office;
• the Child Support Agency;;
• Medicare Australia;
• the legal representatives of the Department of Defence in relation to any common lay (third party) damages action;
• ComSuper (regarding any Commonwealth superannuation entitlements you may have);
• Commonwealth, State and Territory workers’ compensation authorities in relation to a similar injury or medical condition;
• doctors, hospitals and other health care professionals who have provided you with treatment or who are requested to assist in the investigation of your claim; and
• your current and/or previous employer(s)

You must tell DVA if any of the details you provide in this application change.

If you need more information please contact DVA:
National toll Free Number
1800 838 372

Internet
http://www.dva.gov.au/benefitsAndServices/Pages/MRCAbenefits.aspx

Addresses
by Mail:
Department of Veterans’ Affairs
GPO Box 9998
BRISBANE QLD 4001

In person
Contact 1800 838 372 for the address of the nearest VAN office

Who should complete this application?

Persons who were dependants of a member or former member of the Australian Defence Force (ADF) at the time of that person’s death, where the person died as a result of a pre 1 July 2004 defence-related injury or disease; and/or

• persons who are the Legal Representative of a dependant of a member or former member of the ADF who died as a result of a pre 1 July 2004 defence-related injury or disease e.g. a dependant’s solicitor; and/or
• persons who have paid the cost of the funeral or who carried out the funeral (where that cost has not been paid) of a member or former member of the Australian Defence Force (ADF) where the person died as a result of pre 1 July 2004 defence related injury or disease.

NB: This form should not be used for applicants of War Widow(er)s pension under the Veterans’ Entitlements Act 1986 (VEA).If your claim is for damage to personal property (e.g. prescription spectacles or an artificial limb) please contact your nearest DVA office.

Definition of dependant
Dependant means a person who was wholly or partly dependent on the deceased for economic support at the date of the deceased’s death and who was, immediately before the death, in one of the following relationships with the deceased:

1. spouse;
2. de facto partner, being a person who was in either a same-sex or opposite sex relationship with another person which is registered under a prescribed law of a State or Territory. For a list of those laws, please contact the Department of Veterans' Affairs (DVA);
3. de facto partner, being a person who was in a relationship with another person that was not registered, but that was either a same-sex or opposite sex relationship as a couple;
4. father, mother, step-father, step-mother, father-in-law, mother-in-law, grandfather, grandmother, son, daughter, step-son, step-daughter, grandson, grand-daughter, brother, sister, half-brother or half-sister of the deceased.

These terms apply equally to heterosexual and same-sex relationships e.g.

• the parents of the partner of a person in a same-sex relationship are included in the term "father-in-law"and "mother-in-law" ;
• the son or daughter of the partner of a person in a same-sex relationship is the son or daughter of the person.

5. where the deceased was a member of the Aboriginal race of Australia or a descendant of indigenous inhabitants of the Torres Strait Islands - a person who is or was recognised as the deceased's spouse by the custom prevailing in the tribe or group to which the deceased belonged.
6. a person in relation to whom the deceased stood in the position of a parent or who stood in the position of a parent to the deceased.

Dependent for economic support
A spouse, partner or prescribed child ( who is under 16, or is 16 or more but under 25 and is undertaking full-time education, and is not ordinarily in employment or engaged in work on his or her own account) who was, immediately before the death, living with the deceased is automatically taken to have been wholly economically dependent on the deceased at the date of death.

A dependant who would have been wholly or partly dependent but for an incapacity of the deceased that resulted from an injury related to their defence service is taken to have been so dependent on the deceased at the date of death.

Establishing dependency
Possible dependants (other than a spouse, partner or prescribed child who is taken to have been wholly dependent) must demonstrate dependency for economic support by providing all relevant information such as:

• bank statements;
• other records;
• proof of regular support payments by the deceased for economic support; and/or
• court orders which demonstrate the deceased’s legal liability to make regular payments.

Please provide as much evidence of dependency as possible when submitting this claim. The economic link must be in the nature of support and reliance by the dependant. It is not sufficient that the deceased made sporadic gifts of money where they could not be relied on for continuous sustenance.

This application asks about

• The personal details of the person(s) claiming benefits; and
• details of the deceased member.

Completing this application
The information you give should be as complete as possible so that your claim is not delayed. Note that all documents required must be attached for your claim to proceed. Where you are asked to provide copies of documents, you must either provide certified copies or original documents which can be sighted and verified by a DVA officer before being returned to you by registered post.

Please use a black or blue pen and tick boxes as appropriate. Not all questions will apply to you in which case you will be directed to skip to the next relevant one. If you do not have enough space to answer a question, use a separate piece of paper. You are responsible for providing evidence to support your claim. Any such evidence should be included.

If you cannot answer all the questions, fill in as much as you can and get in touch with DVA in your State who will help you.

Make sure you:

• Sign the declaration that the information given on the form is correct at Section G.
• Attach copies of the death certificate, marriage certificate or evidence of the registration of your relationship (where relevant) and the birth certificate for any children.
• Attach relevant medical documents.

Important information
The information sought on this form is required to assess eligibility for a benefit under the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 (DRCA). Dependants of a member of the Australian Defence Force who had service on or after 1 July 2004 may be eligible for benefit under the Military Rehabilitation and Compensation Act 2004. In such cases form D2053 “Claim for Compensation for Dependants of Deceased members and Former members” should be completed or D2663 “Claim for Pension by a Widow, Widower or other Dependant of a Deceased Veteran’ should eligibility be under the VEA.

Please be aware that should this claim be accepted, Tax File Number will be required.

Proving your identity to DVA
When you lodge a claim with DVA, you must show documents from Category A and B to prove your identity. These must be original documents or true and certified copies (see “Who can certify copies of documents” on DVA Fact Sheet DVA06 - Proving your identity to DVA).

Privacy notice

The information provided in this claim required to assess eligibility for benefits under the DRCA. Any information you provide in this claim may be disclosed to the following agencies and bodies for their lawful purposes:

• The Department of Defence;
• Centrelink;
• The Australian Taxation Office;
• the legal representative of the Department of Defence in relation to any Common Law (Third Party) damages action;
• doctors, hospitals and other health care professionals who provided the deceased member with treatment or who are requested to assist in the investigation of this claim.

You must tell DVA if any of the details you provide in this application change.

If you need more information please contact DVA:
National toll Free Number
1800 838 372

Internet
https://www.dva.gov.au/factsheet-mcs01-overview-safety-rehabilitation-and-compensation-act-1988-srca

Addresses
by Mail:
Department of Veterans’ Affairs
GPO Box 9998
BRISBANE QLD 4001

In person
Contact 1800 838 372 for the address of the nearest VAN office

Additional information on line
http://www.dva.gov.au/benefitsAndServices/srca_benefits/Pages/SRCAbenefits.aspx

ADF Health Records

Navy and Air Force
Address: Health Records
Department of Defence
Queanbeyan Annex 4
QUEANBEYAN NSW 2620

Phone: (02) 6266 5923 (Navy or RAAF)
(02) 6266 5809 (Navy or RAAF)
(02) 6266 5816 (Navy)
(02) 6266 5819 (RAAF)

Fax: (02) 6266 5801

Email: healthrecords@defence.gov.au