Purpose of this form
Where your visa has been issued electronically and is not endorsed in your passport, please provide a copy of the letter or email issued to you by the Department of Immigration and Citizenship (DIAC).
Visa evidence sent to you from DIAC via email does not need to be certified. The Income Tax Assessment Act 1936 makes the Medicare levy payable by individuals residing in Australia who are eligible for
Medicare. Persons who are not entitled to Medicare can seek an exemption from the Medicare levy in their income tax return. To obtain an exemption, you must not be eligible for Medicare and must apply for Medicare levy exemption certification.
• All Australian arrival stamps
To claim an exemption from the Medicare levy in your income tax return, you may be required to supply a copy of your Medicare levy exemption certification to the Australian Taxation Office (ATO) if requested. In some cases we may request that you provide Australian departure stamps.
Who can certify documents?
A number of people can certify documents. Examples include:
• legal practitioners
• medical practitioners
• police officers
• justice of the peace.
You may be eligible for Medicare levy exemption if you:
• do not hold an Australian permanent resident visa and have not applied for a permanent resident visa.
• did not reside in one of the following countries prior to entering
Australia – the United Kingdom, Northern Ireland, Italy, Malta,
Sweden the Netherlands, Finland, Norway, Belgium or Slovenia.
These countries have a Reciprocal Health Care Agreement with
• are an Australian citizen residing overseas for 5 years or more
(this excludes diplomats, defence force personnel or an employee of the Australian government).
• are a New Zealand citizen that has been residing in Australia for less than 6 months.
For a complete list of people who can certify documents go to ag.gov.au/Publications/Pages/Statutorydeclarationsignatorylist.aspx www.
For more information
For more information or for additional copies of this form go to our website humanservices.gov.au or email firstname.lastname@example.org or call the Medicare Levy
Exemption Certification Unit on 1300 300 271 Monday to Friday, between 8.30 am and 5.00 pm, Australian Eastern Standard Time.
Note: Call charges apply – calls from mobile phones may be charged at a higher rate. www. To claim an exemption
• We require a separate application form for each financial year.
(A financial year runs from 1 July to 30 June.)
• When we have assessed and processed your application, we will send you the certificate, or a response which details the reason your certification was refused.
• You should not apply for certification for the current financial year unless you are leaving Australia and will be submitting a final income tax return before the end of the financial year.
• If a tax agent prepares the application, the tax agent must complete the Tax agent details under question 19 of the application form.
Queries relating to the following should be directed to the ATO.
• Deductions of the Medicare levy from salary or wages
• Medicare levy surcharge.
Filling in this form
• Please use black or blue pen
• Print in BLOCK LETTERS
• Mark boxes like this with a ✓ or 7
• Where you see a box like this
Go to 5 skip to the question number shown. You do not need to answer the questions in between. The following documents must be submitted when lodging an application for Medicare levy exemption certification.
Returning your form(s) and supporting document(s)
Failing to do so will result in your application being returned and consequently delay the assessment of your application.
Check that you have answered all the questions you need to