Completing the Statement form (SS075) 106-07110010

Customer needs to provide their personal details: name, address and payment that is received or being claimed.

Usually completed by a Service Officer on behalf of the customer. However, the customer has the option of completing the form themselves.

The form is used for Services Australia payments.

Note: if the customer does not want the Service Officer to complete the form on their behalf, cross out the text that is not applicable on the statement, or provide a blank piece of paper for the customer to write their own statement.

Introductory text reads as follows:

I have been told that I can write this statement myself, but I would prefer that an officer from Services Australia write it for me.

I am aware that giving false or misleading information is a serious offence.

If the customer requires an interpreter, the Interpreter must read the statement to the customer then complete the interpreter section.

If the form is completed by the Service Officer on the customer's behalf it must be read aloud to the customer or by the customer.

Customer must sign the form acknowledging that the information is complete and correct to the best of their knowledge.

The Service Officer's name and signature is also required.