Department of Communities Tasmania
DISABILITY, hOUSING AND cOMMUNITY sERVICES – dISABILITY AND COMMUNITY SERVICES /

Self-Directed Funding in Tasmania

Acquittal and Review Form

A requirement of receiving Self-Directed Funding (SDF) is that each participant (or their nominated person) reviews the success of their SDF Plan over the past six months.

Completion of this form is required every six months whilst you are receiving SDF.

This acquittal form contains five sections:

  1. General Information
  2. Outcomes Review
  3. Financial Review
  4. Agreement and Authorisation
  5. Documentation Checklist.

If you are receiving SDF under the Direct Payment model, you will need to complete this entire form yourself and provide documentation as per the Documentation Checklist and requested by Disability and Community Services. If you are receiving funding under the Financial Intermediary or Service Provider Managed models, you will need to complete Section 1, 2, and 4 and your financial intermediary/service provider will need to complete Section 3, 4 and 5.

You will need to return this form within 28 days of the review date noted in your SDF Plan.

This form can be returned via:

Email:

Mail: Individual Funding Unit, GPO Box 125 Hobart Tas 7000

If you have any questions regarding this form, please contact your SDF Planner at your local Gateway Service.

Section 1 – General Information

1. Contact Details
1.1 My Details / Name: / Date of Birth:
Address:
Email:
Telephone Number: / Mobile Number:
1.2 Nominated Person (if applicable) / Name: / Relationship to Client:
Address:
Email:
Telephone Number: / Mobile Number:
1.3 SDF Plan Dates / From: / To:
1.4 Review Date

Section 2 –Outcomes Review

2. Outcomes - please list all your goals, what the outcomes were as listed in your SDF Plan, and a quick review of how the goals have been achieved or worked towards in the past six months in the table below (adding additional rows as necessary).
Goal – (from your SDF Plan, eg, 4.1.1) / Outcome - (listed against the Goal in your SDF Plan) / Review (this is your personal assessment of how well SDF funding assisted you to achieve the outcome of your goal. E.g, did you achieve your goal? Did you partly achieve your goal? Did the funding assist you like you thought it would? Is the SDF model you’ve chosen still the most appropriate? What were the positives from the past six months related to each goal? Were there any negatives from the past six months related to each goal? Do you require further funding to better achieve your goal? If so, have you put an application in to the Gateway?)

Section 3 – Financial Review

3. Expenditure - The goals and funds from your SDFPlan should be used to populate the below table to acquit your SDF Plan.
No. (from your Expenditure Plan) / Funding Full Year Effect (relating to the number from your Expenditure Plan in the previous column) / Funding Year to Date (As the review and acquittal occurs every six months, this will be half of the full year effect funding) / Funding Expended Year to Date (how much funding you have actually spent in the last six months) / Funding Remaining / Comments (if more or less funding has been expended than expected at this stage, you will need to provide an explanation here)
Total / $ / $ / $ / $
4. Agreement and Authorisation - I/we, the undersigned, agree that all information and documentation provided are correct.
10.1 Participant / My Name:
My Signature: / Date:
10.2 Nominated Person
(if applicable) / Name:
Signature: / Date:
Relationship to Person Applying for self-directed funding:
10.3 Service Provider
(if applicable) / Name:
Position:
Service Provider:
Signature: / Date:
5. Documentation Checklist (check that you have included all the documentation you need to)
Documents / Included – detail the documents provided, how many, etc.
Bank Statements
Cheque Stubs
Invoices
Remittance Advices
Receipts
Other (please detail)

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