Re-imbursement Form

MyPlan Purchase Payment Request Form

Participant details

Full name:

Date of birth:

NDIS number:

Payments for NDIS Plan-managed supports

Support Item (Category)	Paid/Unpaid	Purchase / Invoice Date	Quantity	Amount Paid (GST Inclusive)

Total amount of this payment request (GST Inclusive): $0.00

Third party details (if applicable)

Full name:

Date of birth:

Relationship to participant:

Statement

Please confirm the following by checking the boxes:

I confirm that the information provided on this form is true and correct, and meets the NDIS terms and conditions.

I have not previously claimed these purchases (i.e., I am not using this form to make a claim for something I have already been paid for).

All invoices are attached, and copies of the invoices are kept for a minimum of five years.

I understand that the information provided is accurate and complete, and that the NDIS reserves the right to audit any claims.

I have attached all relevant invoices.

Signature

Full name:

Relationship to participant:

Date:

Signature:

Bank Account Details (EFT)

Account Name:

BSB:

Account Number: