Bank Account Details

Account where reimbursement will be paid, ensure details provided are correct. Find Wellbeing accepts no responsiblility for payments made to incorrect accounts based off the information provided on this form.

Have we processed a reimbursement for this bank account before?

A maximum of 5 payments receipts can be submitted per form.

Details of each payment receipt must be provided separately, failure to do so will result in a rejected claim.

Provider's Name/Supplier's Name *

ABN (Australian Business Number)

This number is 11 digits

Payment Receipt Date *

Payment Receipt Number (If no reference ID is provided, put N/A) *

Total $0.00 *

Only the NDIS contribution will be claimed and paid

Description & purpose of services and/or items *

Please upload your payment receipt(s) *

Drag & Drop

Submission

Submitted Date *

Declaration

By submitting this claim (or claims), you declare that the supports and/or items have been received and paid in full, and that they comply with the "reasonable and necessary" criteria under NDIS legislation. You also confirm that the claimed items or supports are aligned with your plan goals and fall within your approved funding categories. Furthermore, where a receipt is provided as proof of payment but does not include the participant’s name or NDIS number, you declare that the receipt pertains to an item and/or support that was purchased solely for the participant’s use and/or benefit.

Signature_NDIS Participant *

Clear

The individual completing this agreement must be the authorised signee