WARNING: It is an offence under the Criminal Code (WA) to knowingly or recklessly give materially false or misleading information in order to obtain a financial advantage.
	I am under 22 years of age		I am over 22 years old	
I 		student number:		
	(Full Name)			
of					
	(Home address)			
State that:
	I do not currently receive a Centrelink benefit (e.g. Austudy, Youth Allowance, Abstudy)	
				
	I have applied for a Centrelink benefit		I have not applied for a Centrelink benefit	
				
	I was granted a Centrelink benefit		I was not granted a Centrelink benefit	
				
I was not granted a Centrelink benefit for the following reasons (please attach Centrelink correspondence to this document):	

	
My total gross income  for the previous two financial years was:	
	Year	Amount	
Last Financial Year:		$	
The Previous financial year to the one above		$	
My Partners total gross income for the previous financial year was:	
Last Financial Year:		$	
The Previous financial year to the one above		$	
The number of people financially dependent on the abovementioned income/s (spouse, children other family members and myself):		
The age/s of the dependent child/children (student/s) are:		

Members of my family have the following investments (if you have no other investments please enter 0.00 as the dollar amount):	
Investment Properties to the value of:	$	
Share Portfolio to the value of:	$	
Other Investments to the value of:	$	
and	
I wish to provide the following additional information:	
	
DECLARATION:  The information provided above is true and complete in every particular and I have not withheld any information that I believe is relevant to my eligibility or otherwise for a scholarship, the subject of this application	
			
(Signature)		(Date)