Reparations scheme form 2: claiming on behalf of another person

Department of Aboriginal and Torres Strait Islander Partnerships
Form 2: Claiming on behalf of another person
Reparations Scheme
Stolen Wages and Savings
Application Form
PRIVACY STATEMENT
The Department of Aboriginal and Torres Strait Islander Partnerships is collecting information to assess
your claim under the Reparations Scheme. This gives effect to Queensland Government policy. Refer to
the department’s website (www.datsip.qld.gov.au) for full privacy statement.
REGIONAL OFFICE LOCATIONS
TORRES REGION
SOUTH WEST QUEENSLAND
ƒƒ Thursday Island
1/46 Victoria Parade
Ph: 4069 1243
ƒƒ Toowoomba
162 Hume Street
Ph: 4593 2101
FAR NORTH QUEENSLAND
ƒƒ Cairns
65-67 Spence Street
Ph: 4232 4232
NORTH QUEENSLAND
ƒƒ Ipswich
117 Brisbane Street
Ph: 3819 7604
SOUTH EAST QUEENSLAND (NORTH)
ƒƒ Caboolture
33 King Street
Ph: 5490 1091
ƒƒ Mackay
44 Nelson Street
Ph: 4862 7001
SOUTH EAST QUEENSLAND (SOUTH)
ƒƒ Mount Isa
52 Miles Street
Ph: 4747 2089
ƒƒ Logan
6 Ewing Road
Ph: 3080 4700
ƒƒ Townsville
187-209 Stanley Street
Ph: 4799 7470
CENTRAL QUEENSLAND
Reparations Unit
ƒƒ Rockhampton
209 Bolsover Street
Ph: 4938 4690
Reply Paid 86597
CITY EAST QLD 4002
[email protected]
ƒƒ Hervey Bay
50-54 Main Street
Ph: 4125 9366
Free Call: 1800
619 505
WHO IS THIS APPLICATION FOR?



Applying on behalf of a deceased person (the claimant); or
Applying on behalf of a medically unfit claimant (eg as a carer); or
Applying on behalf of the claimant as a Guardian or Attorney (Enduring Power of Attorney)
Note: Must provide evidence of Guardian or Attorney.
If you are claiming for yourself, please fill out separate Form 1 only.
YOUR CONTACT DETAILS
Name:
Postal address:
Suburb:
State:
Phone home: (
)
Work:
Postcode:
(
)
CLAIMANT DETAILS
Note: Claimant is any person who had wages/savings controlled under the ‘Protection Acts’, who was born on or before
31 December 1959 and who was alive on 9 May 2002.
Mr / Mrs / Miss / Ms (circle)
First name (in full):
Middle name(s):
Last name:
Junior / Senior (circle if appropriate)
Was the claimant known by any other name?
 Yes  No
e.g. Traditional / Adopted / Nicknames:
Claimant’s
date of birth  Male
(Day / Month / Year)
 Female
Note: Proof of date of birth is to
be supplied with this completed
application.
A certified photocopy of at least
one (1) of the following:
• Birth Certificate / Extract of Birth
• Death Certificate
• Driver Licence
• Passport
• Pension Card /Senior Card
Did the claimant identify as
 Aboriginal
 Torres Strait Islander
 Both Aboriginal and Torres Strait Islander
 Papua New Guinean
 Other (specify)
Claimant’s residential address (or last known address)
No:
Street:
Suburb:
State:
Postcode:
Claimant contact numbers
Home: (
Work: (
)
)
Mobile: (
)
Other: (
)
Reparations Scheme – Application Form | Department of Aboriginal and Torres Strait Islander Partnerships
ADDITIONAL INFORMATION
Was the claimant married or living in a defacto relationship?
 Yes  No
If yes, provide details of claimant’s spouse or partner(s)
Date of birth: (If known)
Name:
Date of birth: (If known)
Name:
Details of claimant’s parents
Date of birth: (If known)
Mother’s name:
(First Name / Middle Name / Married Name)
Mother’s maiden name:
Date of birth: (If known)
Father’s name:
Junior / Senior
DECEASED CLAIM
If claiming on behalf of a deceased person, that person must have been alive on the 9 May 2002 to be
eligible for this payment.
Date of death
(Day / Month / Year)
Note: Proof of date of death to
be supplied with application. A
certified photocopy of at least
one of the following:
• Funeral Notice
• Order of Service
• Medical Certificate or the
Cause of Death
• Burial Certificate
• Death Certificate.
Have the funeral or memorial expenses for the deceased person been paid?
 Yes
 No
If yes, who paid for the funeral or memorial? Copy of paid invoice / receipt must be supplied.
If no, please supply full details of funeral company (Name and address)
Do you know if the deceased person had a Will?
 Yes
Note: If yes, a certified copy of the Will is required when lodging this application or please provide
address of The Public Trustee Office where the Will is held.
 No  Don’t know
Your relationship to the deceased person
 Husband / Wife / Partner
 Father / Mother
 Son / Daughter
 Brother / Sister
 Other (specify)
CLAIMANT’S WORK HISTORY, WAGES AND SAVINGS
Year(s) (When)?
Type of work
(What work did you do?
e.g. Stockman, domestic)
Name of place
Where?
(e.g. Station, convent. private
(Name of town/Community)
home/s)
Example: 1920
Stockman
Crella Park
Via Cloncurry
Did the claimant have any other savings or income, such as child endowment?
If yes, please provide details:
AUTHORISED CONTACT
Please nominate an additional contact person
Name:
Address:
Suburb:
Phone home: (
State:
)
Work:
Postcode:
(
)
DECLARATION SECTION
Note: This section is to be signed by the person completing this form on behalf of a deceased or medically unfit person.
I, (print name) , confirm this information is correct to
the best of my knowledge. I also understand and give permission for the information supplied on this form
to be cross-matched against information supplied under previous Queensland Government reparations
schemes.
Signature: Date:
INTERNAL OFFICE USE ONLY
Claim ID
number:
Duplicate claim:
 Yes  No
Original
claim ID:
Regional Office
Date application form received:
Date application form received:
Date stamp here
Date stamp here
Application received by:
Application processed by:
Print name
Date:
/
/ 20
Print name
Date:
/
/ 20