ATTACHMENT B - FORM FOR ATTACHMENT TO QS CLAIM FORM

Commonwealth Department of Veterans' Affairs

DVA file No. (if known): ......................

QUALIFYING SERVICE APPLICATION

FOR THE PURPOSE OF EXEMPTING DISABILITY PENSION FROM

THE DEPARTMENT OF HEALTH AND FAMILY SEVRVICES

INCOME TEST ON DAILY AGED CARE RESIDENT FEES

SURNAME:GIVEN NAMES:

Aged care resident?

No

Yes

Spouse if applicable

SURNAME:GIVEN NAMES:

Aged care resident?

No

Yes

I hereby wish to establish service pension qualifying service for the purpose of having disability pension exempted from the Department of Health and Family Services income testing of daily aged care residents fees.

Signed:....../....../......