Alcohol Questionnaire This form relates to your claim for pension in respect of the death of (_________________________). The information you supply will assist in deciding eligibility for benefits under the Veterans' Entitlements Act 1986 and/or Military Rehabilitation and Compensation Act 2004. For your claim to be accepted, the circumstances must meet the conditions prescribed by the Repatriation Medical Authority in the appropriate Statement of Principles. An ex-service organisation, such as Legacy, can assist you in completing this form and provide you with advice on how the factors identified in the Statement of Principles may apply to your case. It is important that you give as much information as possible in completing this form to ensure all the particular circumstances of your claim are considered. Veteran's Details Surname Given Names DVA File Number Report Detail 1. What is your relationship to the veteran? 2. When did you first meet the veteran? 3. Did the veteran ever drink alcohol on a regular basis? (For the purposes of this question a regular basis includes an average of 3-4 standard drinks of alcohol per week or above or occasional ‘binge’ type drinking. It does not include such irregular drinking as a glass or two of alcohol only a few times a year such as on special occasions, birthdays, etc.) No  – Please sign the form and return it to the Department. Yes  4. When did the veteran commence to drink alcohol? 5. What alcohol did the veteran drink? (Please describe the types of alcohol; eg beer, or wine, or spirits or combination of these.)
Alcohol Questionnaire This form relates to your claim for pension in respect of the death of (_________________________). The information you supply will assist in deciding eligibility for benefits under the Veterans' Entitlements Act 1986 and/or Military Rehabilitation and Compensation Act 2004. For your claim to be accepted, the circumstances must meet the conditions prescribed by the Repatriation Medical Authority in the appropriate Statement of Principles. An ex-service organisation, such as Legacy, can assist you in completing this form and provide you with advice on how the factors identified in the Statement of Principles may apply to your case. It is important that you give as much information as possible in completing this form to ensure all the particular circumstances of your claim are considered. Veteran's Details Surname Given Names DVA File Number Report Detail 1. What is your relationship to the veteran? 2. When did you first meet the veteran? 3. Did the veteran ever drink alcohol on a regular basis? (For the purposes of this question a regular basis includes an average of 3-4 standard drinks of alcohol per week or above or occasional ‘binge’ type drinking. It does not include such irregular drinking as a glass or two of alcohol only a few times a year such as on special occasions, birthdays, etc.)  No – Please sign the form and return it to the Department.  Yes 4. When did the veteran commence to drink alcohol? 5. What alcohol did the veteran drink? (Please describe the types of alcohol; eg beer, or wine, or spirits or combination of these.)
CRD904_3.docx