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State/territory Postcode

State/territory Postcode

NAT 73404-06.2013

HECSHELP benet application formaths, science, education and nursing(including midwifery) graduates

Complete this application if you meet allthe eligibilityrequirements as a maths, science, education or nursing(including midwifery) graduate.

COMPLETING YOUR APPLICATIONnRefer to theinstructionsto help you complete this application.

nEnsure you sign the declaration before lodgment.

nMake a copy of your application for your own records.

If you are filling in this form on screen complete and print yourapplication in one session (data entered cannot be saved whenyou close the file).

If you are filling in this form by hand:

nprint clearly in BLOCK LETTERS using a black or blue pen.

nplace X in allapplicable boxes.

Only complete this application once the income year(financial year) you are applying for has ended.

For your application to be processed, you must lodge yourincome tax return for the income year (1 July 30 June).

You must complete this application for each income yearyou apply.

Section A: Personal details

We are authorised by the Taxation Administration Act 1953to collect your TFN. You are not required by law to provide yourTFN. However, quoting your TFN reduces the risk of administrative errors that could delay the processing of your application.

1 Your tax le number (TFN)

2 Your full name

Family name

First given name Other given name/s

Title: Mrs Miss Ms OtherMr

Has any part of your name changed since completing your eligible course of study?

Provide your previous family and first name.

Go to question 3.

Yes

No

Previous family name

Previous rst name

3 Your postal addressProvide the address where you want your mail sent.

Suburb/town/locality

Have you changed your postal address since your last tax return?

Print your postal address as it was when you last dealt with us.

Go to question 4.

Yes

No

Suburb/town/locality

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Day Month Year

4 Your date of birth

Daytime phone number (including area code) Mobile phone number

5 Your contact numbers

If we need to ask you about your application, it is quicker by telephone.

Section B: Course details

6 Your course

8 The place where you completed your course

The name of your higher education provider.

If you are eligible to apply for more than one type of benefit provide additional course details (covering questions 68)for each eligible course on a separate sheet of paper and include with this form. For example, you meet the eligibilityrequirements as a maths or science graduate and as an education graduate. Make sure you include your full nameand TFN on each sheet of paper.

Day Month Year

7 The date you completed your course

As shown on your Academic Transcript or Testamur.

If you are a maths or science graduate, the date you completed your course of study must be after 30 June 2008.

If you are an education or nursing (including midwifery) graduate, the date you completed your course of study must beafter 30 June 2009.

Section C: Occupation details

If you have more than one eligible occupation, provide details (covering questions 911) on a separate sheet of paperand include with this form. Make sure you include your full name and TFN on each sheet of paper.

9 Your occupation

Provide your maths, science, education or nursing (including midwifery) occupation (see the Instructions for a list of eligibleoccupations). If your occupation is not listed, you are not eligiblefor the benet.

Provide the name of your payers (employers) registered business or trading name. For example, XYZ Secondary College.

10 Your payers registered business or trading name

Daytime phone number (a contact number must be provided)

Provide the name of your payer (employer). For example, your payroll officer,human resource manager or area that organised your payroll.

11 Your payers contact details

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Section D: Declaration

PrivacyWe are authorised by the Higher Education Support Act 2003 and taxation laws, to collect the information requested onthis application. We need this information to help us administer these laws and to assist us in determining your eligibilityfor the HECSHELP benefit.

If you need more information about how the tax laws protect personal information, or you have any concerns about howthe ATO handles personal information, phone 13 28 61between 8.00am and 6.00pm, Monday to Friday.

Penalties may be imposed for giving false or misleading information.

Declarationn I declare that the information given on this application, including any attachments, is accurate and complete.

n I understand that I cannot withdraw my application once it has been processed.

Signature

Date

Day Month Year

Lodging your application

Send your completed application, including any attachments, to:

Australian Taxation OfcePO Box 1032ALBURY NSW 2640

Make a copy of your application for your own records before you send it.

13 Number of weeks employed in your occupation after completing your course

Maths/Science Education Nursing (including midwifery)

If you worked the full income year (1 July 30 June) enter 52 in the relevant box below.

If you only worked part of the income year, and need help calculating the weeks you can claim,go to question 13 in the Instructions.

12 Income year you are applying for

Enter the income year you are applying for 1 July 20 30 June 20

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