Instructions

Verification of Relationship Status

(SC321)

This form is used to record information from a person (a referee) nominated

by you, about your relationship status.

When to use this form Use this form if you are single with a dependent child and you get, or are claiming, Parenting Payment Single
or JobSeeker Payment. You are required to have this form completed to verify your relationship status.
This is a request for information made under the Social Security (Administration) Act 1999.

How to choose a Your referee must:

suitable referee • be 18 years of age or over
• not be your parent, step parent, sibling or child
• not be your correspondence nominee
• not be your most recent ex partner.
Your referee should also be a person who is familiar with your circumstances. In some cases, you may not
be able to ask a referee to complete this form because you have not told anyone about the separation.
If you are not able to complete this form due to personal circumstances, call us on 132 850 for JobSeeker
Payment, or 136 150 for Parenting Payment Single, as soon as possible so we can discuss your options.
Services Australia may contact your referee to discuss information they have provided on this form.

Returning your form Check that all required questions are answered and that the form is signed and dated.
Return this form and any supporting documents:
• online (excluding identity documents) using your Centrelink online account. For more information,
go to servicesaustralia.gov.au/submitdocumentsonline
www.

• by post to:
Services Australia
Centrelink
PO BOX 7800
CANBERRA BC ACT 2610
• in person at one of our service centres, if you are unable to use your Centrelink online account.
Note: It is your responsibility to return this form, not the responsibility of your referee.

For more information Go to servicesaustralia.gov.au/moc or visit one of our service centres.

www.

Call us on 132 850 for JobSeeker Payment, or 136 150 for Parenting Payment Single.
We can translate documents you need for your claim or payments for free.
To speak to us in other languages, call 131 202.
Note: Call charges may apply.
If you have a hearing or speech impairment, you can contact the TTY service on Freecall™ 1800 810 586.
A TTY phone is required to use this service.

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Notes—1 of 2
Definition of a partner If you have a partner, we generally consider you a member of a couple. Under social security law, we consider
you a member of a couple if you are either:
• married
• in a registered relationship
• in a de facto relationship.
A registered relationship is where your relationship is registered under a law of a state or territory.
A de facto relationship is where you and your partner are in a relationship similar to a married couple
but are not married or in a registered relationship.
We may still consider you a member of a couple if you are not physically living with your partner.
For example, your partner may fly-in fly-out or live away for work, like military or oil rig workers.
For more information, go to servicesaustralia.gov.au/moc
www.

SC321.2003
Notes—2 of 2
 Instructions

Verification of Relationship Status

(SC321)

Filling in this form Privacy notice

• Use black or blue pen.
• Print in BLOCK LETTERS.
6 You need to read this
Privacy and your personal information
The privacy and security of your personal information is
Section 1 – Customer to complete important to us, and is protected by law. We need to collect
this information so we can process and manage your
applications and payments, and provide services to you.
1 Your Centrelink Reference Number (if known)
We only share your information with other parties where you
have agreed, or where the law allows or requires it. For more
information, go to servicesaustralia.gov.au/privacy
www.

2 Your name
Mr Mrs Miss Ms Other Declaration

Family name 7 I declare that:

• I have read the ‘privacy and personal information’ notice at
question 6.
First given name • the information I have provided in this form is complete and
correct.
I understand that:
Second given name
• the person (referee) providing the information about my
relationship status may be contacted.

Your signature
3 Have you been known by any other name(s)?
Include:
On completion of this form,
print and sign by hand
• name at birth • alias
• name before marriage • adoptive name
• previous married name • foster name. Date
• Aboriginal or skin name / /

No Go to next question
Yes Give details below You have now finished your section of the form.
Other name You need to take the back section to your referee
for their completion.

Type of name (for example, name at birth)

If you have more than 1 other name, provide a separate sheet

with details.

4 Your date of birth

/ /

5 Your contact phone number

CLK0SC321 2003

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 Section 2 – Referee to complete 14 Using the space below, in your own words tell us why you
answered the way you did at question 13.

You must answer all the questions and give as much detail as
you can.
As the referee, you must:
• be 18 years of age or over
• not be the customer’s parent, step parent, sibling or child
• not be the customer’s correspondence nominee
• not be the customer’s most recent ex partner.
For the definition of a partner, refer to page 2 of the Notes, or go to
www.

servicesaustralia.gov.au/moc

8 Your name
Mr Mrs Miss Ms Other
Family name

First given name

9 Your date of birth If you need more space, provide a separate sheet with details.
/ /
Privacy notice
10 Your contact phone number
15 You need to read this
Privacy and your personal information
The privacy and security of your personal information is
11 Read this before answering the following questions. important to us, and is protected by law. We collect this
information to provide payments and services. We only share
The following questions are about the person who has your information with other parties where you have agreed,
asked you to complete this form. This is the person listed in or where the law allows or requires it. For more information,
Section 1. go to servicesaustralia.gov.au/privacy
www.

Answer the questions to the best of your knowledge.

Make sure you complete and sign the statement at the end.
Declaration
12 What is your relationship to the person listed in Section 1?
16 I declare that:
• I have read the ‘privacy and personal information’ notice at
question 15.
• the information I have provided in this form is complete and
13 To the best of your knowledge, what is the person’s (listed in correct.
Section 1) current relationship status?
I understand that:
Single • Centrelink may contact me about the information I have
Partnered provided.
• giving false or misleading information is a serious offence
and may be punishable by up to 12 months imprisonment.

Your signature

On completion of this form,

print and sign by hand

Date
/ /

Return this form to the person listed in Section 1 as soon as

completed.

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