Instructions

Claim for
Pandemic Leave Disaster Payment

When to use this form You cannot use this form for a period before 9 December 2021.

•
•
•
•

servicesaustralia.gov.au/covid19
www.

Online services

www.servicesaustralia.gov.au/centrelinkuploaddocs

Filling in this form

•
•
• Go to 1
180 22 66.

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EM252.211229
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Who is eligible to
receive this payment? •
•
•
•

–
–
–
•

How much will I be

paid?

9 December 2021.

Is this payment
taxable?

•
•

How will payments be

made? 180 22 66

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How long do I have to www. servicesaustralia.gov.au/covid19
claim?

What I may need to

provide
within
112 days.
servicesaustralia.gov.au/identity
www.

•
•
•

within 28 days.

For more information servicesaustralia.gov.au/covid19

www.

131 202.

TTY service
1800 810 586

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 This page has been left blank intentionally.

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 Instructions
Claim for
Pandemic Leave Disaster Payment
(EM252)

1 4
1 2 5 5 8 5 7 1 2 C No

servicesaustralia.gov.au/covid19
2
No
Yes Go to next question
servicesaustralia.gov.au/covid19

Yes Go to next question Tick all that applies

Go to 6
3
payment. Go to 6

• Go to 6
here
•

•
payment.
•
servicesaustralia.gov.au/covid19

servicesaustralia.gov.au/covid19

6
Tick all that applies
Go to 4 No Go to next question

Yes
Go to 6
servicesaustralia.gov.au/covid19

Go to 6

Go to 6

Go to 8
Go to 8

payment.

servicesaustralia.gov.au/covid19

CLK0EM252 211229
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7 12

Phone

1 Letter

No Yes

2
13
9 / 01 / 2022

About you
No Yes
14 Your name
3

No Yes ernawaty
need more space

8
15
06 / 01 /2022 Include:
• name at birth •
• •
9 • • foster name.
•

No Go to next question
Yes
must

From
13 / 01 / 2022 20 /01 / 2022

10
No
Yes

11
16
nsw health

17 Your date of birth

26 / 01 / 1992
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18 24
3610,393 pitt street, sydney,nsw No

servicesaustralia.gov.au/covid19
Postcode 2000

19
Yes

/ /
Postcode

25
20 Read

servicesaustralia.gov.au/em
No Go to next question
www.

Yes
Home phone number
servicesaustralia.gov.au/covid19
No Yes

4501992923

About your employment

erna_yenz@yahoo.com 26

21 who was born in Australia shuk bakery

No Go to next question
Yes Go to 25

22 4 3 6 0 8 1 1 6 3 7 4

40 mitchell st,north bondi

23

Postcode 2026
/ / Go to 25

0403575361

27
Passport number

No

servicesaustralia.gov.au/covid19

Yes Go to next question

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 28 Privacy notice
06 / 01 /2022
34 You need to read this
Privacy and your personal information
29
important to us and is protected under the Privacy Act 1988.
No Go to 31
servicesaustralia.gov.au/privacy
www.

Yes Go to next question

30 •
•
Disaster Payment
No •

Yes
From
/ / / /

31 Consent

From 35
06 / 01 / 2022 20 / 01 / 2022
•

32
No Go to next question information
Yes •
26 to 31
•

Payment Type your name or insert your e-signature.

If returning by fax, print and sign by hand.
33

Date
19 / 01 / 2022
anz

0 1 2 1 4 2 Next steps
1
need to.
472658361 2
this form.

ernawaty
Returning this form
online

servicesaustralia.gov.au/centrelinkuploaddocs
You can fax 1300 727 760.

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