Instructions

Claim for
Pandemic Leave Disaster Payment

When to use this form You cannot use this form for a period before 9 December 2021.
Use this form if you are in need of financial support because you have been informed
by a health official to self-isolate or quarantine from 9 December 2021 because of the
following reasons:
• you have tested positive with COVID-19
• you have been in close contact with a person who has tested positive with COVID-19
• you care for a child, aged 16 years or under, who has tested positive with COVID-19
• you care for a child, aged 16 years or under, who has been in close contact with a
person who has tested positive with COVID-19.
You can also use this form if you are caring for a person (other than a child) who has
tested positive with COVID-19, or if you are caring for a person who has a disability or
severe medical condition who must self-isolate or quarantine.
If you have been informed by a health official to self-isolate or quarantine, you would
have been contacted directly by phone, email, SMS or letter.
For more information on a health official in your state or territory or claims for periods
before 9 December 2021, go to servicesaustralia.gov.au/covid19
www.

Online services You can upload this form, with any supporting documents, online using your Centrelink
online account.
For more information about how to access an online account or how to lodge documents
online, go to servicesaustralia.gov.au/centrelinkuploaddocs
www.

Filling in this form You can complete this form on your computer using Adobe Acrobat Reader, and some
browsers, or you can print it.
If you have a printed form:
• Use black or blue pen.
• Print in BLOCK LETTERS.
• Where you see a box like this Go to 1 skip to the question number shown.
If you need help to claim this payment, call us on 180 22 66.

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Who is eligible to You may be eligible to receive this payment if you:
receive this payment? • are aged 17 years and over
• are an Australian resident or the holder of an eligible visa
• live in a state or territory of Australia
• were informed to self-isolate or quarantine, or are caring for someone who has tested
positive with COVID-19, or who is under instruction to self-isolate or quarantine
• were likely to have worked during the period of self-isolation, quarantine or caring
for someone who has tested positive with COVID-19, or who is under instruction to
self-isolate or quarantine
• are not able to work and are not receiving any income, earnings or salary from
employment
• have no appropriate leave entitlement left (including any special pandemic leave)
or your employer is not able to pay your leave entitlements due to their financial
hardship. Appropriate leave includes:
– sick leave
– leave for the purposes of caring for another person (personal leave or carer’s leave)
– pandemic leave
• are not receiving an Australian Government income support payment, ABSTUDY Living
Allowance, Paid Parental Leave or Dad and Partner Pay.

How much will I be The Pandemic Leave Disaster Payment is a lump sum payment of $750.
paid? One lump sum payment is payable per person for each 7 day period of directed
quarantine, self-isolation or caring. The 7 day period or part thereof must fall on or after
9 December 2021.
A separate application must be made for each 7 day period being claimed. Each applicant
must apply separately.
The Pandemic Leave Disaster Payment is exempt from all Australian Government means
testing.

Is this payment The Pandemic Leave Disaster Payment is taxable.

taxable? This means you will need to include it in your income tax return.
If you get family assistance, you will need to include the Pandemic Leave Disaster
Payment in your family income estimate as taxable income.
You need to do this if you or your partner get:
• Family Tax Benefit
• Child Care Subsidy.
The easiest way to view and update your family income estimate is online. You can use
your Centrelink online account through myGov or the Centrelink Express Plus mobile app.
If you have a child support assessment, the payment will form part of your adjusted
taxable income for Child Support. It must be included in any income estimate you lodge
for the current financial year. The easiest way to view and update your information
is online. You can use your Child Support online account through myGov or the Child
Support Express Plus mobile app.

How will payments be Payments will be made to a nominated account held in your name. A joint account is
made? acceptable. If you do not have an account, contact Services Australia on 180 22 66
for alternative arrangements.

EM252.211229
Notes—2 of 3
How long do I have to For details on closing dates for this payment, go to servicesaustralia.gov.au/covid19
www.

claim?

What I may need to You may need to provide 1 document showing your proof of birth or proof of arrival in
provide Australia, and 2 other approved documents, for example, a drivers licence and bank
or financial institution card to prove your identity. We may ask you to provide approved
photo identification at one of our service centres, agents or access points within
112 days.
For more information, go to servicesaustralia.gov.au/identity
www.

You may also need to provide additional evidence that you are eligible for this payment,
for example:
• proof of your residential address
• proof of employment such as payslips or letter of employment
• evidence of instructions from the state or territory government to quarantine or
self-isolate
• proof of a positive test result for COVID-19.
If you cannot provide any of the above information to us with your claim, you should submit
this claim without delay and provide the supporting documents to us within 28 days.

For more information Go to servicesaustralia.gov.au/covid19

www.

We can translate documents you need for your claim for free.
To speak to us in your language, call 131 202.
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.

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 Instructions
Claim for
Pandemic Leave Disaster Payment
(EM252)

1 Your Customer Reference Number (if known) 4 Are you living with the person?
2 1 1 2 0 0 0 1 0 x No You will not be eligible for this payment.
For more information, go to www.

servicesaustralia.gov.au/covid19
2 Are you currently in Australia? To check which claim is suitable for you, go to www.

No You will not be eligible for this payment. servicesaustralia.gov.au/paymentfinder

For more information, go to www.

Yes Go to next question

servicesaustralia.gov.au/covid19
To check which claim is suitable for you, go to
5 This question is about the person, with a disability or severe
www.

servicesaustralia.gov.au/paymentfinder
medical condition, you are caring for.
Yes Go to next question Tick all that applies
The person has a carer in receipt of Carer Go to 6
3 This question will help us determine your eligibility for this Payment on their behalf
payment. The person receives assistance under the Go to 6
If you: NDIS scheme
• are in Australia on a visa that does not allow you to work The person would normally attend a specialist Go to 6
here school or workplace for a person with a
• are receiving a payment, pension or benefit (not including disability
Family Tax Benefit) from the Australian Government
• have received a state or territory based COVID-19 None of the above You will not be eligible for this
payment for the same period you are claiming payment.
• have access to appropriate leave from your employer For more information, go to www.

then you will not be eligible for this payment. servicesaustralia.gov.au/covid19

For more information, go to www.
To check which claim is suitable for
servicesaustralia.gov.au/covid19 you, go to www.

To check which claim is suitable for you, go to www.

servicesaustralia.gov.au/paymentfinder
servicesaustralia.gov.au/paymentfinder
I am not able to attend work and earn an income because: 6 Has anyone else claimed this payment due to caring for the
Tick all that applies person while they are required to quarantine or self-isolate?
I am caring for a person with a disability Go to 4 No Go to next question
or severe medical condition who must
self-isolate or quarantine Yes You will not be eligible for this payment.
I am caring for a child aged 16 years and Go to 6 For more information, go to www.

under who has tested positive with COVID-19 servicesaustralia.gov.au/covid19

To check which claim is suitable for you, go to
I am caring for a person who has tested Go to 6
www.

servicesaustralia.gov.au/paymentfinder
positive with COVID-19
I am caring for a child aged 16 years and Go to 6
under who has been in close contact with
someone who has tested positive with
COVID-19
I have tested positive with COVID-19 Go to 8
I have been in close contact with someone Go to 8
who has tested positive with COVID-19

None of the above You will not be eligible for this

payment.
For more information, go to www.

servicesaustralia.gov.au/covid19
To check which claim is suitable for
you, go to www.

servicesaustralia.gov.au/paymentfinder CLK0EM252 211229

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7 What is the name of the person(s) you are caring for? 12 How were you notified?
If you are caring for a person(s) other than your child, you SMS
must have their consent, or the consent of their legal
Phone
guardian, to provide their name below.
Email
1 Family name Letter
Other Give details below

First given name

Are you this person’s legal guardian? No Yes

2 Family name
13 What date were you notified?
/ /
06/01/2022
First given name

About you
Are you this person’s legal guardian? No Yes
14 Your name
3 Family name
Mr Mrs Miss Ms Other
Family name
First given name
haidari
First given name
Are you this person’s legal guardian? No Yes nargis
If you need more space, provide a separate sheet with details. Second given name

8 What date did you, or the person you are caring for, enter
quarantine or self-isolation? 15 Have you been known by an other name(s)?
/ /
04/01/2022 Include:
• name at birth • alias
• name before marriage • adoptive name
9 What 7 day period are you claiming for? • previous married name • foster name.
• Aboriginal or skin name
Only one claim can be made for each 7 day period of
quarantine, self-isolation or caring. No Go to next question
If your quarantine, self-isolation or caring period extends
Yes Give details below
past 7 days or you have a new period of quarantine,
self-isolation or caring, you must make a new claim. Other name
From To
/ /
04/01/2022 / /
13/01/2022
Type of name (for example, name at birth)
10 Were you directly informed to self-isolate?
No
Yes If you need more space, provide a separate sheet with details.

11 Who informed you to self-isolate?

16 Your gender
NSW Health
Male
Female

17 Your date of birth

/ /
10/09/1996
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18 Your residential address 24 Do you hold a visa that entitles you to work in Australia?
55 albert rd auburn No You will not be eligible for this payment.
For more information, go to www.

servicesaustralia.gov.au/covid19
Postcode 2144 To check which claim is suitable for you, go to www.

servicesaustralia.gov.au/paymentfinder
19 Your postal address (if different to above)
Yes Give details below
Visa subclass Date visa granted
/ /
Postcode

25 Have you/will you receive an Australian Government income

20 Read this before answering the following question. support payment, ABSTUDY Living Allowance, Paid Parental
Providing a mobile phone number or an email address Leave or Dad and Partner Pay for any day within the 7 day
means you may receive SMS or emails from us. To read the period you are claiming for?
terms and conditions, go to servicesaustralia.gov.au/em
No Go to next question
www.

Your contact details Yes You will not be eligible for this payment.
Home phone number ( ) For more information, go to www.

servicesaustralia.gov.au/covid19
Is this a silent number? No Yes To check which claim is suitable for you, go to www.

servicesaustralia.gov.au/paymentfinder
Mobile phone number 0451 313 795
Alternative phone number ( )
About your employment
Email
[email protected] 26 Your employer details
Name of employer
21 Are you an Australian citizen who was born in Australia? Belgravia health and leisure grp
No Go to next question
Yes Go to 25
Australian Business Number (ABN) (if known)
22 What is your country of birth? 1 8 1 1 8 9 4 0 0 6 3
afghanistan Employer’s address
115 dunmore st
23 What is your country of citizenship?
wentworthville NSW
Australia Date citizenship granted
/ /
Postcode 2145
Go to 25
Contact phone number
Other Give details below
Country of citizenship 288487700

27 Is it likely you would have worked during the period you are
Passport number required to self-isolate, quarantine or care for another person?

No You will not be eligible for this payment.

Country of issue For more information, go to www.

servicesaustralia.gov.au/covid19
To check which claim is suitable for you, go to www.

servicesaustralia.gov.au/paymentfinder

Yes Go to next question

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28 Date last worked Privacy notice
/ /
01/01/2022
34 You need to read this
Privacy and your personal information
29 Does this employer provide access to appropriate leave The privacy and security of your personal information is
entitlements (including any special pandemic leave)? important to us and is protected under the Privacy Act 1988.
No GoClick
to 31to go to 31 For more information about how we manage your personal
information, go to servicesaustralia.gov.au/privacy
Yes Go to next question
www.

Services Australia needs to collect your personal information

so we can:
30 Have you exhausted all appropriate leave entitlements from this • verify your identity
employer? • assess your eligibility to receive the Pandemic Leave
Disaster Payment
No You will not be eligible for this payment. • process and manage your application and payments
You must use all your ‘appropriate’ leave provide related services to you.
entitlements before claiming this payment. Your personal information, including your health information
if relevant, may be shared with Commonwealth, state or
Yes Give details below territory government bodies that are assisting with the public
From To health response to COVID-19. Your information may also
be shared with other parties where you have given your
/ / / / consent, or where permitted by law.

31 What is the period of time you did not work while you were in Consent
self-isolation, quarantine or caring for another person?
From To 35 For the purposes of assessing my application and managing
/ /
04/01/2022 / /
13/01/2022 any payment, I give consent for Services Australia to:
• collect my personal information from other Commonwealth
or state or territory government agencies and organisations,
32 Do you have another employer? including my employer, including my name, address, date of
birth, phone number, employer details and relevant health
No Go to next question information
Yes • use or disclose any relevant information previously collected
You need to provide details from questions about me for Centrelink purposes
26 to 31 for each additional employer.
• disclose my personal or relevant health information to other
Commonwealth, state or territory government agencies and
organisations or my employer.
Payment Type your name or insert your e-signature.
Your signature If returning by fax, print and sign by hand.
33 Where do you want your payment made?
The account must be in your name. A joint account is
acceptable.
Payment cannot be made into an account used exclusively
for funding from the National Disability Insurance Scheme.
Date
Name of bank, building society or credit union
/ /
08/01/2022
commonwealth
Branch number (BSB)
Next steps
0 6 2 1 0 7
1 Check that you have answered all the questions that you
Account number (this may not be your card number) need to.
11252656 2 Check you have completed the signature section and dated
this form.
Account held in the name(s) of
nargis haidari
Returning this form
Return this form online using your Centrelink online account.
For more information, go to www.

servicesaustralia.gov.au/centrelinkuploaddocs
You can fax a printed and signed form to 1300 727 760.
Make sure any accompanying documentation is also clearly
identified with your name.
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