Application for an extension of the provisional allocation period ______

APPLICATION FOR AN EXTENSION OF THE PROVISIONAL ALLOCATION PERIOD

Section 15-7 of the Aged Care Act 1997

Important information for applicants

Under section 15-7 of the Aged Care Act 1997 (the Act), an approved provider who has been granted a provisional allocation of places may apply to the Secretary of the Department of Social Services for an extension of the provisional allocation period.

The provisional allocation period is the period of 2 years after the day on which the allocation is made. For home and flexible aged care, the period of extension, if approved, is

12 months. For residential aged care places, the period of extension is also 12 months unless the Secretary is satisfied that the applicant meets the criteria in the Allocation Principles 1997 (the Principles) for increasing or decreasing the period of extension.

The questions in this form reflect the provisions of section 15-7 of the Act.

Applications must be made at least 60 days before the end of the provisional allocation period, unless a shorter period is allowed by the Secretary. If you need to lodge this application in less than the 60 day period, you should discuss this with the Department and complete Attachment 1.

Please note that if the extension to the provisional allocation period will result in any change to a condition to which the allocation is subject, the approved provider must lodge an ‘Application for a variation of the provisional allocation of places’ prior to this form.

Signatories to this application must be legally authorised to sign for and on behalf of the approved provider and must be key personnel of the provider.

If you are unclear about any of the questions in this application form, please contact 1300 653 227and ask to speak with a Departmental Officer in your relevant state or territory in relation to provisionally allocated residential aged care places:

Please forward the completed application form to the address below:

Aged Care Branch

Department of Social Services

GPO Box 9820

In the capital city of the state or territory in which the residential aged care service is located.

(For ACT services, please send this form to NSW for assessment)

Section A – Approved provider details

A1 Name of approved provider

A2 Postal address of approved provider

PO Box/Street & number
Suburb/Town
State/Territory / Postcode

A3 Name (or proposed name) of the aged care service.

A4 Physical address of the aged care service.

Street number & name
Suburb/Town
State/Territory / Postcode
E-mail address

A5 Contact name (key personnel)

Title / Given name(s) / Family name
Position
Contact phone / Fax
E-mail address
A6 / Is this a new aged care service? / Yes / No

A7 Residential aged care service ID or Home Care Package provider number, or flexible care service number (if applicable – a new service may not yet have a number).

Section B – Reasons for and period of extension

B1 What is the provisional allocation period for the provisional allocation and have any extensions previously been approved in respect of this provisional allocation?

Date the provisional allocation was made (ie: date stated in the Notice of Conditions of Allocation ) / Date on which any current approved extension
expires
dd / mm / yy / dd / mm / yy

B2 Please explain in detail why you need an extension of the provisional allocation period. Attach more sheets if required.


B3 For all aged care places including residential, home care and flexible aged care, the period of extension is 12 months. For residential aged care only the Secretary may approve an increase or a decrease in the 12 month period if the Secretary is satisfied that the applicant meets the criteria in section 39 or 40 of the Principles.

The period of extension will be for 12 months unless a different period is requested with respect to residential places only.

For residential care places only, do you require an extension period different from the standard 12 months?

Yes / No

Please indicate the extension period requested

months

B4 If you have asked for an extension of less than 12 months, what work remains to be completed in relation to the construction of premises?

If there is another reason why an extension of less than 12 months, is appropriate, please provide an explanation in the box below.

For residential and flexible care only

B5 If premises are being built to accommodate the places, section 38(2) of the Principles requires that the Secretary must be satisfied that at least one of the following results is likely to occur if the extension is granted. Please provide details in the boxes below each statement as applicable. Please provide supporting documentation.

B5.1 Work on the premises will be substantially finished before the end of the extended period.

B5.2 Reasonable progress towards the construction of the premises will be made

by the end of the extended period.

B5.3 A substantial amount will be spent by the approved provider, in connection

with work on the premises, to meet the conditions to which the allocation was

subject.

B5.4 If the work on the premises has been delayed by circumstances beyond the

approved provider’s control, work on the premises will proceed satisfactorily

within a reasonable period.
Likely change in the factors.
Imposed as part of the original allocation.

B6 An extension of more than 12 months may be granted if one or more of the following circumstances apply. Please provide details in the boxes below each statement as applicable. Please provide appropriate supporting documentation.

likely change in the factors.
Imposed as part of the original allocation.

B6.1 The need to start or continue construction of the relevant premises at a

time that is related to the maturity of invested funds.

B6.2 The need to comply with a condition of the provisional allocation that was

not imposed as part of the original allocation.

B6.3 A substantial change in the factors associated with the provisional allocation

has occurred or is likely to occur.
Imposed as part of the original allocation.

B6.4 A change to the business relationship between parties involved in the

construction of the relevant premises has occurred.
Likely change in the factors.
Imposed as part of the original allocation.

B6.5 A natural disaster has occurred.

B7 If premises are being built to accommodate the places, please advise the estimated amount and source(s) of funds for the project. If funds are being borrowed, please advise any conditions associated with the borrowing. If funds are being negotiated, please advise the status of negotiation, for example, preliminary discussions, agreement-in-principle reached, contractual arrangements in place. Attach more sheets if required.


B8 If the proposed extension to the provisional allocation period includes additional construction at the same site or new/additional construction at a different site, please provide revised milestones for work that has been completed and dates when you expect unfinished work to be completed, using the table below. Please attach any supporting documentation to this application, for example, include a copy of the land development approval.

Milestone / Date achieved / Date to be achieved
Site/building acquired
Finance approved
Use of land approved
Development application approved
Building application approved
Building work commenced
Building work completed
Selection of staff completed
Care management systems developed
State/Local Government approval obtained
Certification obtained (if applicable)
Accreditation obtained
Commencement of service
Admission of residents

Section C - Endorsement of application

This application can be signed only by those persons who are legally authorised to sign for and on behalf of the approved provider. According to the Criminal Code Act 1995, giving false or misleading is a serious offence. A maximum penalty of 12 months applies.

I/We have read the Aged Care Act 1997 and the Allocation Principles 2014.

I/We declare that all the information set out in all sections completed in this application, and any associated attachments, is true and complete.

I/We declare that the key personnel in my/our service are, and will continue to be, suitable to provide aged care and are not disqualified individuals.

I/We consent to the Secretary of the Department of Social Services obtaining information and documents from other persons or organisations, including the Australian Aged Care Quality Agency and state, territory and Australian Government Departments/authorities, to assist in assessing the application.

Title / Given name(s) / Family name
Name
Position
Signature / Date
/ /
Title / Given name(s) / Family name
Name
Position
Signature / Date
/ /


Attachment 1

If the application has been submitted less than 60 days before the end of the provisional allocation period, provide reasons for the delay.

______This is an approved form for the purposes of the Aged Care Act 1997

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