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The form captures the claimant’s responsibility for managing the budget, authorizes contact if supports do not meet the intended purpose, and requires selection of the relevant support category (personal care, household management, respite, or other). It also records payment preference, confirms the claim information is true, that responsibilities under the Standard Agreement Declaration are met, supporting records are kept for audit, and warns of restricted acts for knowingly misleading information.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/claims-self-verification-form/171545/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/claims-self-verification-form/171545.png","ImageObject",442,249,{"name":88,"@type":89},"Olivia Brown","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-15","2026-09-01",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who completes this self-verification form, and can an agent submit it?","Question",{"text":108,"@type":109},"The form is completed by the named individual or a nominated agent. Both the individual and agent details and sign-off are required.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What support categories can claims be made under?",{"text":113,"@type":109},"Claims can be selected for Personal Care, Household Management, Respite, or Other. The form also allows selecting the specific area, purpose, and support being claimed.",{"name":115,"@type":106,"acceptedAnswer":116},"What confirmations must the claimant provide before submitting the claim?",{"text":117,"@type":109},"The claimant must confirm the information is true and accurate, responsibilities under the Standard Agreement Declaration are complied with, costs/services claimed were incurred or accrued by the claim date, and full records will be retained for audit on request. Knowingly false information is treated as a restricted act and can lead to future exclusion.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},171545,1792043812,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":73,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},16904993612988,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","Self-Verification Template for Claims\nName of individual (or nominated agent):\nI accept that:\nI am fully responsible for the management of my hosted flexible funding budget.\nThe host may contact me, if the supports claimed do not appear to meet the purpose it was intended for\nPersonal Care\nSelect which area, purpose and support your claim is for:\nHousehold Management\nSelect which area, purpose and support your claim is for:\nRespite\nSelect which area, purpose and support your claim is for:\nOther\nThe following areas, purposes and supports could fall under IF Personal Care, IF Household Management or IF Respite.\nPlease select which you would like to claim under:\nSelect which area, purpose and support your claim is for:\nMy claim is to be:\no Reimbursed directly to me\no Paid directly to the provider/organisation\nI confirm, in relation to this claim for payment, that:\nThe claim information is a true and accurate record of the services/supports provided and/or expenses incurred\nI have complied with all of my Responsibilities in the Standard Agreement Declaration – Service Agreement\nall services/supports/expenses for which I have claimed payment have been incurred or accrued by me as at the date of this claim\nI have made, and will retain, full records supporting this claim. I will make these records available for audit on request.\nI understand that if I knowingly mislead or supply false information to the Ministry, this will be regarded as a Restricted Act which may result in my future exclusion from access to a self-managed disability support budget.\nName of individual (or Nominated Agent):\nSignature of individual (or Nominated Agent):\nDate:","cbCaiuksuNXfquU7","https://ap.wps.com/l/cbCaiuksuNXfquU7","docx",46067,"English","# Claimant Information\n## Individual and Signature Details\n# Responsibilities and Declarations\n## Management Responsibility and Contact Authorization\n# Support Category Selection\n## Personal Care / Household Management / Respite / Other\n# Claim Payment Arrangement\n## Reimbursed Directly or Paid Directly to Provider\n# Confirmation and Compliance\n## Accuracy of Record, Incurred/Accrued Costs, Recordkeeping, Audit\n## Restricted Act Notice","[{\"question\":\"Who completes this self-verification form, and can an agent submit it?\",\"answer\":\"The form is completed by the named individual or a nominated agent. Both the individual and agent details and sign-off are required.\"},{\"question\":\"What support categories can claims be made under?\",\"answer\":\"Claims can be selected for Personal Care, Household Management, Respite, or Other. The form also allows selecting the specific area, purpose, and support being claimed.\"},{\"question\":\"What confirmations must the claimant provide before submitting the claim?\",\"answer\":\"The claimant must confirm the information is true and accurate, responsibilities under the Standard Agreement Declaration are complied with, costs/services claimed were incurred or accrued by the claim date, and full records will be retained for audit on request. Knowingly false information is treated as a restricted act and can lead to future exclusion.\"}]","Claims Self-Verification Form | DOCX",1788284096]