Form Submission

Form: COVID-19 Test Isolation Payment Program (F-3464 v1095)

Form Type: Grant Application
Submission ID: GA-F3365406-2705
Submitted: 19/10/2021 1:06 PM
Submitted By: Ikadek Putra

Introduction

Confirmation

I confirm that I have read and understood the Program Guidelines. true

Section 1: Are you eligible to apply?

1. I am 17 years or older true
2. I have been tested for COVID-19 or care for someone who is required to self-isolate
true
following a COVID-19 test
3. I am applying regarding a COVID-19 test taken within the last two weeks true
4. I currently live in Victoria true
5. I am unable to work, or was unable to work, due to having to self-isolate following a
true
COVID-19 test
6. I am not receiving, or was not receiving, any income or earnings from work while
true
self-isolating at home
7. I do not have access to sick leave or carer's leave, or did not have access to any such
leave (including any special pandemic leave), covering the self-isolation period relating to true
the test
8. I am not receiving, or was not receiving, Australian Government income support
true
including JobSeeker payments during the relevant self-isolation period
9. I am not receiving, or was not receiving, another worker support payment, including the
true
Pandemic Leave Disaster Payment, for the same self-isolation period
10. I have followed the self-isolation requirements while waiting for my COVID-19 test
true
results
I agree that I may have to repay the funds if my application is successful but I do not
true
self-isolate while waiting for my test results
11. I have the following documents ready to complete my application
• Current ID (either a Driver Licence or Learner Permit, Medicare Card, Pensioner
Concession Card, Australian Visa (international passport) or Australian Passport)
• Current evidence of my employment (dated within 12 months and clearly showing my
name)
• Evidence that the Department of Health or my employer requested I get tested (this is
only if you are applying to receive this payment for more than one test in a 30-day
true
period).

Please note: uploaded documents must be in PDF, JPEG or PNG format.

Remember, the documents you need to provide have recently changed. If you do not
have the required documents, please call 1800 675 398 and select option 4, then 4 again
before submitting your application.
Section 2: Applicant Details
Title: Mr
First Name (exactly as it appears on your ID): I kadek
Middle Name (only if included on your ID) Dwi adnyana
Last Name (exactly as it appears on your ID): Putra
Date of Birth (exactly as it appears on your ID): 16/12/1983
Are you 17 years old? No
Are you of Aboriginal or Torres Strait Islander origin? No
If we need to contact you by phone do you need an
No
interpreter?

Mobile:
(Please use the number you provided at the time of your
+61447571029
test)
(Please prefix e.g. + 61)
Email: [email protected]
Country: AU
Street Address: 20 Maine Hey Cres
Suburb/Town: Springvale
State: VIC
Postcode: 3171
Are you an Australian Citizen or Permanent Resident? No
Do you hold a current visa with working rights? Yes
Please select the Visa Type Other (please specify)
Other (Please Specify) WC/030
Unfortunately, you do not qualify for this payment. To find out about other supports that may be available to you, please visit the Financial and Other
Support page on the Victorian Government COVID-19 website.

Proof of Identity
Proof of Identity of the Applicant
Australian Visa (international passport)
Proof of Identity Information is required for the person making this application.

Your proof of identity information will be verified after you complete and submit this application.
If your proof of identify information cannot be successfully verified, you will receive an email notification requesting you to log into the portal again, correct any errors and resubmit
your application.

I understand that if my proof of identity cannot be verified, I will receive a

true
follow-up email with instructions to amend my proof of identity details.
I acknowledge that, on receipt of a follow up email, if I do not rectify my
application’s proof of identity details prior to application closing date, my true
application will not be considered by the Department for this program.

Australian Visa (international passport) Details

Visa Number 8269568972692
Passport Number B6032205
Nationality Indonesian
Given Name/s (including middle name/s or initials - exactly as printed on
I Kadek dwi adnyana
your Passport)
Family Name (exactly as printed on your Passport) Putra
Date of Birth 16/12/1983
I agree that the Department is able to validate this information with the
relevant Commonwealth and state agencies, including the Department of true
Home Affairs and Services Australia

Section 3: Covid-19 Test & Employment Details

COVID-19 Test Details

Did you get tested for COVID-19? Yes
Details of the person who got tested (as provided at the testing site)

What date was the test?

(If the COVID-19 test was taken more than
two weeks ago or you select a date in the
future, you are not eligible for the payment. 17/10/2021
This information will be checked. If you have
any questions, please contact 1800 675 398
and select option 4, then 4 again)
Have you received a Test Isolation Payment
No
previously?

Employment Details
Are you self-employed? No
Australian Business Number (ABN) of the
business that you are employed at (use this 65059497004
link for ABN Lookup):
Name of your employer:
(If you have more than one job, where do M & G Vizzarri Pty Ltd
you work the most hours?)
Where is your workplace?
Street Address: 2960 pakenham road
Suburb/Town: Koo wee rup
Postcode: 3981
Please include the following details for your supervisor or manager:
What is your supervisor or manager’s
Carla vizzarri
name?
What is your supervisor or manager’s direct
phone number? (not a switchboard or +61488204340
reception):
I agree that the Victorian Government may
contact my employer to verify the true
information in this application
What industry do you work in? Agriculture
How many hours of paid work have you
missed due to isolating while waiting for your 6-10
COVID-19 test results?
Evidence of Employment
For example: a payslip, letter of employment
or letter of offer from your employer.
Remember, it must show your name and be
dated no more than 12 months ago.

OR

(attachment)
Evidence of Self-Employment
For example: ASIC or ABR confirmation of
registration, Business Activity Statement
(BAS), last PAYG summary or a Statutory
declaration (you can use this link to make
one). Remember, it must show your name,
business name, ABN and be dated no more
than 12 months ago.

Section 4: Bank Account details

If your application is successful, the payment will be made to your nominated bank account.
Australian Bank Account Details
(please enter all details as they appear on your bank statement)
What is the name of your Australian bank account? I kadek dwi adnyana putra
BSB:
(6 digit number without dash, spaces or commas) 063529
Account Number:
10445497
Please re-enter your Account Number below
The BSB number and Account number above are correct and match my
Australian bank statement
true
I understand that I will not receive the payment if I enter my bank details
incorrectly.
Has anyone else used these bank details when applying for payment
No
under this program?

Declaration and Agreement (Acknowledgement and Lodgement)

Privacy Statement

In order to assess your application as part of the COVID-19 Test Isolation Payment program, the Department of Jobs, Precincts and Regions (the
Department) will be collecting personal information and health information from you (or where applicable your dependent) to assess eligibility for
grant funding, and to contact you, or where relevant your parent or legal guardian about this application.

I acknowledge that Information collected from me (or where applicable my dependent) in the application process will be used by the Department for
the purposes of assessment of this application, program administration and program review. In undertaking this application it is noted that I (or as a
guardian or carer, my charge) have previously undertaken a test for COVID-19 and am required to self-isolate.

Any personal information or health information collected, held, managed, used, disclosed or transferred by the Department will be done so in
accordance with the Privacy and Data Protection Act 2014 (Vic), the Health records Act 2001 (Vic) and other applicable laws.

I acknowledge in the assessment of this application, it may be necessary for the Department to share my personal information and the fact that I, or
someone for whom I care, has been tested for COVID-19, with other State or Commonwealth Government Departments and agencies including the
Department of Transport and the Department of Health as well as my employer.

Sharing of such information may be necessary to confirm that I am a resident of Victoria and conditions of my employment. Health information
shared between the Department and the Department of Health will be limited to the outcomes of test results.

I acknowledge that Personal Data may be required to be shared to confirm employment with external parties. While only the minimum amount of
required data will be discussed to deliver required outcomes - this may include sharing that I, or a person that I care for has, undertaken a
COVID-19 test.

I confirm that I am authorised to provide the personal identity details presented and I consent to my information being checked with the document
issuer or official record holder via third party systems for the purpose of confirming my identity.

I confirm that I have obtained consent from my supervisor or manager, to provide their personal information to the Department as part of this
application, which may be used to contact them to confirm the information in this application

The Department is committed to protecting the privacy of personal information and health information. The Department’s Privacy Policy can be
found online at https://djpr.vic.gov.au/privacy

You can gain access to personal information (as defined in the Privacy and Data Protection Act 2014) or health information (as defined in the Health
Records Act 2001 Vic) which the Department holds about you in certain circumstances specified by legislation.

Enquiries about access to information should be directed to the Department’s Privacy Unit by emailing [email protected].
Applicant’s Consent

1. By submitting this application, including personal information and any health information provided, each applicant or an applicant’s carer or legal
guardian, confirms that they consent, and have the consent of any person whose personal and/or health information is contained or collected as
part of the COVID-19 Test Isolation Payment program, including but not limited to a person for whom they care for who is subject to a COVID-19
test, to provide that information to the Department, and for the Department to disclose that personal and/or health information to other parties
including, but not limited to, other Victorian government departments and agencies, Centrelink and your employer, for the purposes of administering
the COVID-19 Test Isolation Payment program.

2. If you do not provide consent or have not obtained the consent of any person whose personal and/or health information you have provided as
part of this application, the Department will not be able to process this application.

Applicant Declaration
I understand that if any information provided in this application and the claim submission is found to be untrue or misleading, the grant will be
repayable on demand, the matter may be referred to law enforcement and penalties may apply.
By checking this box I am making the above declaration and agree to the
terms of the grant as set out in this online form and the Program true
Guidelines:
Full name of the person completing this application: i kadek dwi adnyana putra
Did you receive any help to complete this application? No