Application for an Form

Offshore Humanitarian visa

Refugee and Humanitarian (Class XB) visa
842
Department of Home Affairs

The Department of Home Affairs (the Department) About this form

acknowledges that Aboriginal and Torres Strait Islander peoples Important – Please read this information carefully before you
are the traditional custodians of the Australian land. complete your application. When you have completed your
application we recommend that you keep a copy for your
Life in Australia – Australian values records.
The Australian Government encourages people to gain an
understanding of Australia, its people and their way of life, Australia’s offshore Humanitarian Program
before applying for a visa to live in Australia. There are a limited number of places available each year under
This includes understanding that the English language, as the the program. In setting the size of the program, the Australian
national language, is an important unifying element of Government considers:
Australian society. Australian society is also united through the • the views of the United Nations High Commissioner for
following shared values: Refugees (UNHCR);
• respect for the freedom and dignity of the individual; • the views of the Australian community; and
• freedom of religion (including the freedom not to follow • Australia’s capacity to settle refugees and people in need.
a particular religion), freedom of speech, and freedom of
association; Requirements for each visa subclass
• commitment to the rule of law, which means that all people
Your application will be assessed against the 5 visa subclasses of
are subject to the law and should obey it;
the Refugee and Humanitarian (Class XB) visa class. To be
• parliamentary democracy whereby our laws are determined granted a visa, you must be assessed as meeting the requirements
by parliaments elected by the people, those laws being for one of these subclasses. These are set out in Australia’s
paramount and overriding any other inconsistent religious or Migration Act and Regulations and the main requirements for
secular ‘laws’; each subclass are:
• equality of opportunity for all people, regardless of their
gender, sexual orientation, age, disability, race, or national or Refugee (subclass 200)
ethnic origin; • You are living outside your home country; and
• a ‘fair go’ for all that embraces: • you are subject to persecution in your home country; and
– mutual respect; • you are in need of resettlement.
– tolerance; The UNHCR provides advice to the Australian Government on
– compassion for those in need; and the need for resettlement.
– equality of opportunity for all.
In-country Special Humanitarian (subclass 201)
The Life in Australia booklet provides more information on the
values that Australians share and their way of life. This booklet is • You are in your home country; and
available in a wide range of languages and can be obtained from • you are subject to persecution.
www.homeaffairs.gov.au Only a small number of places are available under this subclass.
You are encouraged to read the Life in Australia booklet before
Global Special Humanitarian (subclass 202)
completing this application form. If you have difficulty, or are
unable to read the booklet, you may have the content of it • You are living outside your home country; and
explained to you, for example, by a friend or relative. This form • you are subject to substantial discrimination amounting to
contains a statement, that you must sign, that confirms you gross violation of your human rights in your home country;
understand and will undertake to conduct yourself in accordance and
with the values of Australian society (as explained in the booklet) • you have included a valid form 681 Refugee and Special
and will obey the laws of Australia. Humanitarian Proposal with your application.
This statement must also be signed by each person aged 18 years Form 681 needs to be completed by an Australian citizen or
or over, who is included in this form. permanent resident, eligible New Zealand citizen, or community
organisation in Australia (a ‘proposer’) who is willing to support
Who should use this application? your application.
You should use this form if you are outside Australia and wish to As the government does not fund travel costs for this visa
apply for entry to Australia on humanitarian grounds. This class subclass, your proposer is expected to assist you and any
of visa includes the following 5 subclasses: dependants in meeting costs associated with travel to Australia
• Refugee (subclass 200) and initial settlement after arrival.
• In-country Special Humanitarian (subclass 201) Emergency Rescue (subclass 203)
• Global Special Humanitarian (subclass 202) • You are subject to persecution in your home country; and
• Emergency Rescue (subclass 203) • there are urgent and compelling reasons for you to be resettled
• Woman at Risk (subclass 204). in Australia.
You should also use this form if you are applying under the Requests for urgent assistance under this subclass are usually
Community Support Program. made on your behalf by the UNHCR.
© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 1
Woman at Risk (subclass 204) To be eligible for the grant of a humanitarian visa under the
• You are a woman living outside your home country; and ‘split family’ provisions for immediate family:
• subject to persecution in your home country or are registered • you must apply within 5 years of the permanent Protection,
with the UNHCR as being ‘of concern’; and humanitarian or Resolution of Status visa being granted to
• without the protection of a male relative; and your proposer;
• in danger of victimisation, harassment or serious abuse • your proposer must complete a form 681 Refugee and Special
because you are female. Humanitarian Proposal (available from the Department’s
website) for you to submit together with your own visa
Children under 18 application;
Children under the age of 18 who have no parents, or who have • your proposer must have declared you to the Department as
been separated from their parents, may also be granted a visa in an immediate family member before the grant of their own
one of the subclasses listed above. However, the Australian visa.
Government must be satisfied the child’s entry to Australia is in
the best interest of the child and that the rights of the parents, if Partner
any, are properly considered. ‘Partner’ means your spouse or de facto partner (including
If any children under 18 who are members of the family unit same-sex partners).
and included in this application are not your biological children,
you must provide information and documentation as to who Residential address
their birth parents are/were.
You must advise the Department where you intend to live while
your application is being dealt with, or if you change your
Community Support Program residential address after your application has been lodged. Failure
The Community Support Program enables communities and to give a residential address will result in your application being
businesses, as well as families and individuals, to propose invalid. A post office box address will not be accepted as your
applicants with employment prospects (and their families) and residential address.
to support their settlement in Australia. Only Approved
Proposing Organisations (APOs) may propose people for entry Your application
to Australia in the Community Support Program.
You should answer the questions in this form truthfully and fully
Information about the Community Support Program is available and attach any supporting documents. Forms that are
from the Department’s website www.homeaffairs.gov.au/CSP incomplete could delay a decision being made on your
Note: Your APO must complete form 1417 Community Support application, or your application could be refused.
Program Proposal by Approved Proposing Organisation. Your APO Not all applicants are interviewed and a decision may be taken
must lodge both of these forms (form 842 and form 1417) on the information provided in your application only. You need
electronically following the directions on the Department’s to make sure you include all details about your situation in your
website https://immi.homeaffairs.gov.au/help-support/ application.
departmental-forms/online-forms/special-humanitarian-visa-
If you need more space than is provided in this form for any of
submission-form or by post.
your answers, attach a separate page, clearly marking the
The Department will share your personal information that was question number the page relates to. Additional pages must be
collected during the processing of your application with your signed and dated by each person aged 18 years or over included
APO. If a visa is granted, this information may be used by the in this application.
APO to enable delivery of settlement services and support. Your
APO may also share your personal information with other Who should be included in this application?
organisations, known as Supporting Community Organisations,
so they can provide services to you to help you settle in Australia. You should include in this form ALL members of your family
unit. Your family unit includes your spouse, de facto partner
(including same-sex partner), dependent children outside
‘Split family’ provisions for immediate family of permanent Australia and other dependent relatives who usually live with you
Protection (Class XA), humanitarian (Class XB) or (eg. a dependent parent). ‘Dependent’ means wholly or
Resolution of Status (Class CD) visa holders. substantially dependent on you or your partner for financial,
You should use this form if, within the last 5 years, a member of psychological or physical support.
your ‘immediate family’ was granted either a: Details of dependent family members NOT included in your
• permanent Protection visa (subclass 866); or visa application should be included at Question 12. If you fail to
declare immediate family members in your application, they may
• humanitarian visa (subclasses 200, 201, 202, 203 or 204); or
not be able to access the ‘split family’ provisions for immediate
• Resolution of Status (Class CD) visa (subclass 851). family members (referred to above) if they apply for a visa at a
Note: Your proposer must not have been an illegal maritime later time.
arrival who arrived on or after 13 August 2012. Non-dependent family members (eg. married children or
Note: Under the ‘split family’ provisions, ‘Immediate family’ children over 18 who are independent) should complete their
means you are the spouse, de facto partner (including same- own form 842 if they wish to be considered for entry to Australia
sex partner), dependent child or in certain circumstances a on humanitarian grounds.
parent of the person in Australia who is proposing your entry
(that is, your proposer has completed form 681). Integrity of application
Note: You can only apply as a parent under these ‘split family’ The Department is committed to maintaining the integrity of
provisions if your child in Australia is under 18 years of age. the visa and citizenship programs. Please be aware that if you
provide us with fraudulent documents or claims, this may result
in processing delays or your application being refused.

842 (Design date 05/22) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2022

What documents should you attach to this application? Change of circumstances
Two (2) passport-sized photographs of each person included in If your circumstances change in any way after you have lodged
the application, that have the name of the person written on the this form (eg. you or a family member enters into a new
back. relationship, becomes engaged, or marries), you must inform the
Department. If a child is born to you (or any other person
Supporting documents included in this application) after the application is lodged,
The documents you must provide are requested throughout this the child will be included in your application if details are
form. There is also a document checklist in Part Q of this form provided before a final decision is made on your application.
and you should carefully check you have provided all the listed Information on updating your circumstances is available on the
documents. Department’s website
You should also provide all documents necessary to support https://immi.homeaffairs.gov.au/change-in-situation
your humanitarian claims.
Copies of documents must be certified as true copies of the Processing information
original by a Justice of the Peace, Commissioner for You should be aware that there is strong interest in this class of
Declarations, or a person before whom a Statutory Declaration visa and it may take a long time to finalise your application.
may be made under the Statutory Declarations Act 1959. Outside
You may need to have a medical and an x-ray examination as
Australia, a person who is equivalent to a Justice of the Peace or a
part of the assessment of your application. You may also be asked
Commissioner for Declarations must certify copies.
to undergo medical treatment as part of the assessment of the
If you do not provide all the necessary documents, a decision visa application. The Australian Government reserves the right to
may be made on the information you have provided. It is in conduct character checks on all adult applicants. Details of your
your interest to support your application with as much application are not passed on to your home country.
information as possible at the time of application.
The Australian Government will pay the costs related to medical
If you are not able to provide any of the documents listed at examinations for all humanitarian visa applicants, except those
Part Q, please provide a written explanation why the in the Community Support Program. The Australian
documents are not available. Government will also pay for the travel to Australia of applicants
Under no circumstances should you submit false documents. granted a subclass 200, 201, 203 or 204, but not 202, visa.

Where can you lodge this application? Important information about privacy
Applicants wishing to be considered for a Class XB visa in the The Privacy Act 1988 contains 13 Australian Privacy Principles
Refugee category must lodge their form at an Australian overseas which regulate the way that the Department collects and handles
mission. For addresses, please see the Department’s website personal information. Information about how the Department
www.homeaffairs.gov.au/about/contact/offices-locations collects, uses and discloses personal information for its key
Electronic lodgement is available to applicants wishing to be functions can be found in form 1442i Privacy notice. More
considered for a Class XB visa under the Global Special information about the Department’s general information
Humanitarian Program (subclass 202), the ‘split family’ handling practices (including form 1442i) can be found in the
provisions for immediate family members and the Community Department’s Privacy policy at
Support Program. https://www.homeaffairs.gov.au/access-and-accountability/
our-commitments/privacy
Further information, including details on how to lodge a Global
Special Humanitarian (subclass 202) visa application The Department is careful to protect the privacy of all
electronically, is available from the Department’s website applicants. Care will be taken to make sure that details of your
https://immi.homeaffairs.gov.au/visas/getting-a-visa/visa- application do not reach your home country.
listing/global-special-humanitarian-202
Review rights
Is there an application or processing charge? If your application is refused, it is not possible to obtain a review
Applicants in the Community Support Program must pay a Visa of the decision by the Administrative Appeals Tribunal.
Application Charge. Further information on the Visa
Application Charge is available on the Department’s website Settlement services
https://immi.homeaffairs.gov.au/visas/getting-a-visa/fees- If you are granted a humanitarian visa (subclasses 200, 201, 202,
and-charges/current-visa-pricing/other 203 or 204), information on the personal possessions that you
Other applicants do not pay a charge to lodge this application. may take with you to Australia is available from the office that
granted your visa.
Is there a charge for the form? The Department provides a range of services to help refugee and
No – forms 681, 842 and 1417 are free and may be obtained humanitarian entrants settle in Australia. This assistance may
from the Department’s website include being met on arrival by a service provider and taken to
www.homeaffairs.gov.au/allforms/ accommodation, help to register for income support, help to
arrange medical appointments, information about your new
community, and attending English language classes.
Interviews and requests for more information
Note: If you are granted a humanitarian visa in the Community
Interviews are not always necessary. We will advise you if you are
Support Program, settlement services will be provided to you by
required to attend an interview or if you need to provide more
your APO, in conjunction with any Supporting Community
documents or information.
Organisation.

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 3

Immigration assistance Appointing a migration agent/exempt person
A person gives immigration assistance to you if he or she uses, or To appoint a migration agent/exempt person you should complete
claims to use, his or her knowledge or experience in migration Part M – Options for receiving written communications.
procedure to assist you with your visa application, request for Your migration agent/exempt person should complete form 956
ministerial intervention, cancellation review application, Advice by a registered migration agent/exempt person of providing
sponsorship or nomination. immigration assistance.
In Australia a person may only lawfully give immigration Form 956 is available from the Department’s website
assistance if he or she is a registered migration agent or is exempt www.homeaffairs.gov.au/allforms/
from being registered. Only registered migration agents may
receive a fee or reward for providing immigration assistance. Options for receiving written communications
If an unregistered person in Australia, who is not exempt from If you do not appoint a migration agent/exempt person you may
registration, gives you immigration assistance they are still authorise another person, in writing, to receive written
committing a criminal offence and may be prosecuted. communications on your behalf. This person is called the
Restrictions on giving immigration assistance, charging fees for authorised recipient.
immigration assistance and restrictions on charging fees for
immigration representations apply even where the APO lodges Authorised recipient information
form 842 (this form) on behalf of a client in the Community All written communication about your application will be sent
Support Program. to your authorised recipient, unless you indicate that you wish to
Migration agents in Australia have health and/or character information sent directly to you. If
your visa application is subject to proposal form 681 or
Migration agents in Australia must be registered with the Office form 1417 and you wish all communication to be sent to your
of the Migration Agents Registration Authority (Office of the proposer, you will need to complete Question 18 and
MARA) unless they are exempt from registration. Question 47 on this form.
Migration agents outside Australia The Department will communicate with the most recently
Migration agents who operate outside Australia do not have to appointed authorised recipient as you may only appoint one
be registered. The Department may give some overseas agents an authorised recipient at any time for a particular application.
ID number. This number does not mean that they are registered. You will be taken to have received any documents sent to that
Note: Some Australian registered migration agents operate person as if they had been sent to you.
overseas.
Migration agent information Consent to communicate by email
A migration agent is someone who can: The Department may use a range of means to communicate
• advise you on the visa that may best suit you; with you. However, email will only be used if you indicate your
• tell you the documents you need to submit with your agreement to receiving communication in this way.
application; To process your application the Department may need to
• help you fill in the application and submit it; and communicate with you about sensitive information, for example,
• communicate with the Department on your behalf. health, police checks, financial viability and personal
relationships. Emails, unless adequately encrypted, are not secure
If you appoint a migration agent, the Department will assume and may be viewed by others or interfered with.
that your migration agent will be your authorised recipient,
unless you indicate otherwise. If you agree to the Department communicating with you by
email, the details you provide will only be used by the
Your migration agent will be the person with whom the Department for the purpose for which you have provided them,
Department will discuss your application and from whom it will unless there is a legal obligation or necessity to use them for
seek further information when required. another purpose, or you have consented to use for another
You are not required to use a migration agent. However, if you purpose. They will not be added to any mailing list.
use a migration agent, the Department encourages you to use a The Australian Government accepts no responsibility for the
registered migration agent. Registered agents are bound by the security or integrity of any information sent to the Department
Migration Agents Code of Conduct, which requires them to act over the internet or by other electronic means.
professionally in their clients’ lawful best interests.
If you authorise another person to receive documents on your
Information on migration agents, including a list of registered behalf and they wish to be contacted electronically, their
migration agents, is available on the Office of the MARA website signature is required on form 956 or 956A to indicate their
www.mara.gov.au consent to this form of communication.
You can also access information about migration agents on the Note: Email is the fastest means of communication available and
Department’s website www.homeaffairs.gov.au the Department prefers to communicate by email because this
Exempt persons results in faster processing.
The following people do not have to be a registered migration
agent in order to provide immigration assistance, but they must
not charge a fee for their service: Home page www.homeaffairs.gov.au
• a close family member (spouse, de facto partner, child, parent, General Telephone 131 881 during business hours
brother or sister); enquiry line in Australia to speak to an operator (recorded
• a member of parliament or their staff; information available outside these hours).
• an official whose duties include providing immigration If you are outside Australia, please contact
assistance (eg. a Legal Aid provider); your nearest Australian mission.
• a member of a diplomatic mission, consular post or
international organisation.
Please keep these information pages for your reference
842 (Design date 05/22) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2022
 Application for an Form

Offshore Humanitarian visa

Refugee and Humanitarian (Class XB) visa
842
Department of Home Affairs

Please open this form using Adobe Acrobat Reader.

Either type (in English) in the fields provided or print this form and complete it (in English) using a pen and BLOCK LETTERS. PHOTOGRAPH
Please attach two (2)
Tick where applicable 3 recent passport sized
photographs of yourself
Part A – Summary of people included in this application AND
• Only include members of your family who are dependent on you or your partner. all members of your
• A dependant is a person who is wholly or substantially dependent on you or your partner for financial, psychological or family unit included in this
physical support. application
Note: Clearly write the
• The term ‘partner’ in this form, means your spouse or de facto partner (including same-sex partners).
name of the person on the
• Non-dependent family members (eg. adult independent children, married children or children over 18 who have their back of each photograph
own income) should complete their own application form. However you should still list any non-dependent children at
Question 14 and Question 15 of Part D on this form.
• You must attach evidence of the identity of each person (eg. certified copy of birth certificate, marriage certificate,
passport), wherever this is available. If you do not have identity documents, please attach an explanation as to why you
no longer have them.
• For each person included who is not the main applicant’s partner or child under 18 years, you must attach a statement
explaining why this person is dependent on the main applicant.
• It is important that all names are spelled correctly and dates of birth are accurate.

1 How many people are included in this application? Relationship status

Married legally Engaged Widowed
2 Give details of the main applicant Married by De facto Never married or
tradition/custom Separated been in a de facto
Family name A1 relationship
Married religiously Divorced
Given names
For your relationship status (other than ‘never married or been in a
Name in own de facto relationship’), give the following details:
language or Day Month Year
ethnic script Date this happened
Sex Male Female Indeterminate /
Intersex / Unspecified Place this happened
Day Month Year
Your previous name (if applicable)
Date of birth

Place of birth Town/city

Do you currently have more than one partner (other than any partner
Country included in this visa application)?

No
Citizenship Yes Please provide details
If stateless, write your previous country of citizenship
Current country of
residence
Day Month Year
Date you arrived in
this country
Select
Status in this country See below for codes to be used
If you have indicated you are ‘never married or been in a de facto
relationship’ or ‘engaged to be married’, are you currently in any other
form of a relationship (eg. boyfriend/girlfriend)?
‘Status in this country’ codes
No
C = Citizen
PR = Permanent resident Yes Please provide details
TR = Temporary resident
S = Student
V = Visitor/Tourist
R = Refugee
I = Illegal resident
A = Asylum/protection applicant
O = Other – give details on a separate page

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 5

3 Give details of all other people included in this application

1. Family name A2 2. Family name A3

Given names Given names

Name in own Name in own
language or language or
ethnic script ethnic script
Sex Male Female Indeterminate / Sex Male Female Indeterminate /
Intersex / Unspecified Intersex / Unspecified
Day Month Year Day Month Year

Date of birth Date of birth

Place of birth Town/city Place of birth Town/city

Country Country

Citizenship Citizenship
If stateless, write your previous country of citizenship If stateless, write your previous country of citizenship
Relationship status Relationship status
Married legally Engaged Widowed Married legally Engaged Widowed
Married by De facto Never married or Married by De facto Never married or
tradition/custom Separated been in a de facto tradition/custom Separated been in a de facto
relationship relationship
Married religiously Divorced Married religiously Divorced
Relationship to Relationship to
main applicant main applicant
Is this person biologically related to the main applicant? Is this person biologically related to the main applicant?
No Explain how they are related to the main applicant No Explain how they are related to the main applicant

Yes Describe the precise biological relationship Yes Describe the precise biological relationship

842 (Design date 05/22) - Page 6 © COMMONWEALTH OF AUSTRALIA, 2022

3. Family name A4 4. Family name A5

Given names Given names

Name in own Name in own
language or language or
ethnic script ethnic script
Sex Male Female Indeterminate / Sex Male Female Indeterminate /
Intersex / Unspecified Intersex / Unspecified
Day Month Year Day Month Year

Date of birth Date of birth

Place of birth Town/city Place of birth Town/city

Country Country

Citizenship Citizenship
If stateless, write your previous country of citizenship If stateless, write your previous country of citizenship
Relationship status Relationship status
Married legally Engaged Widowed Married legally Engaged Widowed
Married by De facto Never married or Married by De facto Never married or
tradition/custom Separated been in a de facto tradition/custom Separated been in a de facto
relationship relationship
Married religiously Divorced Married religiously Divorced
Relationship to Relationship to
main applicant main applicant
Is this person biologically related to the main applicant? Is this person biologically related to the main applicant?
No Explain how they are related to the main applicant No Explain how they are related to the main applicant

Yes Describe the precise biological relationship Yes Describe the precise biological relationship

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 7

 5. Family name A6 6. Family name A7

Given names Given names

Name in own Name in own
language or language or
ethnic script ethnic script
Sex Male Female Indeterminate / Sex Male Female Indeterminate /
Intersex / Unspecified Intersex / Unspecified
Day Month Year Day Month Year

Date of birth Date of birth

Place of birth Town/city Place of birth Town/city

Country Country

Citizenship Citizenship
If stateless, write your previous country of citizenship If stateless, write your previous country of citizenship
Relationship status Relationship status
Married legally Engaged Widowed Married legally Engaged Widowed
Married by De facto Never married or Married by De facto Never married or
tradition/custom Separated been in a de facto tradition/custom Separated been in a de facto
relationship relationship
Married religiously Divorced Married religiously Divorced
Relationship to Relationship to
main applicant main applicant
Is this person biologically related to the main applicant? Is this person biologically related to the main applicant?
No Explain how they are related to the main applicant No Explain how they are related to the main applicant

Yes Describe the precise biological relationship Yes Describe the precise biological relationship

If you need more space, please attach a separate page with the details
Attach evidence of identity of each person included in this application
(eg. certified copies of birth certificates, marriage certificates,
passport, national identity card)

842 (Design date 05/22) - Page 8 © COMMONWEALTH OF AUSTRALIA, 2022

 Part B – Applicants mandated or registered by UNHCR
4 Has any person included in this application been mandated as a refugee or
registered with the United Nations High Commissioner for Refugees (UNHCR)?
No
Yes Give details
Name Refugee Mandate number(s) Country of mandate

Name Refugee Registration number(s) Country of registration

Attach a certified copy of evidence of your refugee status/registration

Part C – Contact details

5 Your residential address (not postal address) 8 Do you agree to the Department communicating with you by email?
Note: You must tell us if your address changes after you lodge this form. No
Yes Provide at least one primary and any secondary email
addresses you can be contacted on
Primary
Postal code
Secondary
6 Your postal address
Secondary
(If the same as your residential address, write ‘AS ABOVE’)
Note: If you wish to nominate a person other than yourself to receive
written communications about this application, you must indicate this
at Part M.
Postal code

7 Your contact telephone numbers (if available)

Country code Area code Number
Telephone ( ) ( )
number
Mobile/cell

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 9

 Part D – Family background 3. Family name

9 Have you or any other person included in this visa application Given names
previously been legally married, in a de facto relationship or in a Previous partner’s full name
customary/traditional/religious marriage that is not legally recognised?
No
Day Month Year
Yes Give details of each person below
Dates of
Note: Include partners who you are divorced or separated relationship From
from or who are missing or deceased.
To
1. Family name How did the relationship end?

Given names
Previous partner’s full name Names of all children from this previous relationship

Day Month Year

Dates of
relationship From

To If you need more space, please attach a separate page with the details
How did the relationship end? Attach a certified copy of previous marriage/divorce documents or
death certificate (if applicable/available)

Names of all children from this previous relationship 10 Do you or any other person included in this application have children
from a previous marriage/relationship, including customary/traditional
marriage?
No
Yes Do they have sole custody of any children under 18 years of
age who are included in this application?
2. Family name No Yes Attach a certified copy of the
custody documents (if available)
Given names Note: Where custody documents are not provided or
assessed as unsatisfactory, the former partner will need to
Previous partner’s full name
provide evidence that he/she consents to any children of
that relationship entering Australia.
Day Month Year
Dates of
relationship From

To
How did the relationship end?

Names of all children from this previous relationship

842 (Design date 05/22) - Page 10 © COMMONWEALTH OF AUSTRALIA, 2022

11 Are there any children included in this application who are not the
3. Family name
biological children of either you (the main applicant) or your partner?
No Given names
Yes Give details of each child Day Month Year

Date of birth
1. Family name
Relationship
Given names to you
Day Month Year Full name of biological father

Date of birth
Relationship Full name of biological mother
to you
Full name of biological father
Whereabouts of biological parents
(if deceased or unknown, please state)
Full name of biological mother

Whereabouts of biological parents

(if deceased or unknown, please state)
Has this child been adopted (formally, customarily or traditionally)
by the main applicant and/or partner?
No
Yes Date custody commenced
Day Month Year
Has this child been adopted (formally, customarily or traditionally)
by the main applicant and/or partner?
No If you need more space, please attach a separate page with the details
Yes Date custody commenced For each adopted child, attach a certified copy of the adoption
Day Month Year
papers (if available) or attach a statement which explains the
circumstances of the adoption

2. Family name

Given names
Day Month Year

Date of birth
Relationship
to you
Full name of biological father

Full name of biological mother

Whereabouts of biological parents

(if deceased or unknown, please state)

Has this child been adopted (formally, customarily or traditionally)

by the main applicant and/or partner?
No
Yes Date custody commenced
Day Month Year

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 11

12 Do you have a husband, wife, de facto partner or any dependants who 13 Is any person included in this application physically separated from you
normally live with you but who are not included in this application? (eg. missing or living at a separate address/location)?
A dependant is a person who is wholly or substantially dependent on No
you or your partner for financial, psychological or physical support. Yes Give details and explain when and where you were last
No in contact with them
Yes Give details and explain why they do not intend to migrate
with you as part of this visa application 1. Family name

1. Family name Given names

Day Month Year
Given names Date of birth
Day Month Year
Relationship
Date of birth to you
Relationship Last contact (when, where and how you were separated)
to you
Reason they are not applying with you

Full residential address (if known)

Postal code
2. Family name

Given names
2. Family name
Day Month Year

Date of birth Given names

Day Month Year
Relationship
to you Date of birth
Reason they are not applying with you Relationship
to you
Last contact (when, where and how you were separated)

3. Family name Full residential address (if known)

Given names
Day Month Year

Date of birth Postal code

Relationship
to you 3. Family name
Reason they are not applying with you
Given names
Day Month Year

Date of birth
Relationship
to you
If you need more space, please attach a separate page with the details
Last contact (when, where and how you were separated)

Full residential address (if known)

Postal code

If you need more space, please attach a separate page with the details

842 (Design date 05/22) - Page 12 © COMMONWEALTH OF AUSTRALIA, 2022

14 Relatives of MAIN APPLICANT
Give details of ALL YOUR parents, brothers and sisters and non-dependent children. You must include half, step and adopted relatives.
If any person listed below is not biologically related to you, you must clearly indicate this.
Note: You must list ALL relatives, whether they are living, deceased, or their whereabouts are unknown. If any relative is deceased or
missing/whereabouts unknown, then you must write ‘DECEASED’ or ‘UNKNOWN’ in the ‘Country where they are now living’ column.
Relationship Status in ‘Relationship status’ codes
Relationship
Sex Date of birth to main Country where they country of N = Never married or been in a
Name status Place and country of birth applicant are now living residence de facto relationship
(use codes
on right) (use codes (use codes M = Married legally
M/F/X Day Month Year on right) on right)
E = Engaged to be married
Your parents Select Select Select S = Separated
F = In a de facto relationship
D = Divorced
W = Widowed
MT = Married by tradition/custom
Mother’s maiden name MR = Married religiously

‘Relationship to main applicant’

Your brothers and sisters Select Select Select codes
PB = Parent – Biological
PA = Parent – Adoptive
PS = Parent – Step
PO = Parent – Other
(attach explanation)
SB = Sibling – Biological (full)
SA = Sibling – Adoptive
SS = Sibling – Step
SO = Sibling – Other
(attach explanation)
CB = Child – Biological
CA = Child – Adoptive
CS = Child – Step
CO = Child – Other
(attach explanation)

‘Status in country of residence’

Your non-dependent children (all children who are not included as dependants in this application) Select Select codes
C = Citizen
PR = Permanent resident
TR = Temporary resident
S = Student
V = Visitor/Tourist
R = Refugee
I = Illegal resident
A = Asylum/protection applicant
O = Other – give details on a
separate page

If you need more space, please attach a separate page listing further names
© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 13
15 Relatives of main applicant’s PARTNER
Give details of ALL YOUR PARTNER’s parents, brothers and sisters and non-dependent children, including children your partner has had with other partners.
You must include half, step and adopted relatives. If any person listed below is not biologically related to your partner, you must clearly indicate this.
Note: You must list ALL YOUR PARTNER’s relatives, whether they are living, deceased, or their whereabouts are unknown. If any relative is deceased or
missing/whereabouts unknown, then you must write ‘DECEASED’ or ‘UNKNOWN’ in the ‘Country where they are now living’ column.
Relationship ‘Relationship status’ codes
Status in
Relationship to main N = Never married or been in a
Sex Date of birth Country where they country of
Name status Place and country of birth applicant’s de facto relationship
are now living residence
(use codes partner M = Married legally
on right) (use codes
(use codes on right) E = Engaged to be married
M/F/X Day Month Year on right)
S = Separated
Your partner’s parents Select Select Select F = In a de facto relationship
D = Divorced
W = Widowed
MT = Married by tradition/custom
MR = Married religiously
Your partner’s mother’s maiden name
‘Relationship to main
applicant’s partner’ codes
Your partner’s brothers and sisters Select Select Select PB = Parent – Biological
PA = Parent – Adoptive
PS = Parent – Step
PO = Parent – Other
(attach explanation)
SB = Sibling – Biological (full)
SA = Sibling – Adoptive
SS = Sibling – Step
SO = Sibling – Other
(attach explanation)
CB = Child – Biological
CA = Child – Adoptive
CS = Child – Step
CO = Child – Other
(attach explanation)

Your partner’s non-dependent children (all children who are not included as dependants in this application) Select Select ‘Status in country of residence’
codes
C = Citizen
PR = Permanent resident
TR = Temporary resident
S = Student
V = Visitor/Tourist
R = Refugee
I = Illegal resident
A = Asylum/protection applicant
O = Other – give details on a
separate page

If you need more space, please attach a separate page listing further names

842 (Design date 05/22) - Page 14 © COMMONWEALTH OF AUSTRALIA, 2022

 Part E – Links to Australia
16 Has any person included in this application ever applied for an Australian visa (permanent or temporary) before?
No
Yes Give details

Family and given name

Date of application File number Application approved?
(If all persons included in this application, Where was the application lodged?
(if known)
write ‘All’) Day Month Year No Yes Not decided

If you need more space, please attach a separate page with the details

17 Do you or your partner have any relatives NOT INCLUDED IN THIS VISA APPLICATION who have current Australian visa applications under consideration?
No
Yes Give details

Date of application File number Type of visa application

Family and given name Where was the application lodged?
Day Month Year (if known) (if known)

If you need more space, please attach a separate page with the details

18 Is any person included in this application being proposed (on form 681 or form 1417) for entry to Australia by a person or organisation in Australia?
No
Yes Give details of your proposer or Approved Proposing Organisation (in case of a Community Support Program application)
Family name

Given names
OR
Organisation name

Contact person

Relationship of the
proposer to you
Telephone number (Area code )

Note: Proposers in the Global Special Humanitarian (subclass 202) program must complete form 681 Refugee and Special Humanitarian
Proposal and lodge both form 681 and this form (form 842) together. There is no charge for lodging or processing form 681.
Note: APOs under the Community Support Program must complete form 1417 Community Support Program Proposal by Approved Proposing
Organisation and lodge both form 1417 and this form (form 842) together. For charges associated with lodging and processing form 1417, refer
to the Visa Pricing Table https://immi.homeaffairs.gov.au/visas/getting-a-visa/fees-and-charges/current-visa-pricing/other
These forms are available from the Department’s website www.homeaffairs.gov.au

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 15

19 ‘Split family’ provisions for ‘immediate family’ members
Are any people included in this application members of the immediate family of a person in Australia who, in the last 5 years,
was granted a Refugee/Humanitarian visa outside Australia, or a Protection or Resolution of Status (Class CD) visa inside Australia?
‘Immediate family’ means a spouse or de facto partner (including same-sex partner), dependent children,
or parent (if your child in Australia is under 18 years of age)
No
Yes Give details of the immediate family member who was granted the visa
Family name

Given names

File number (if known)

Name of the person in this
application they are related to
Relationship

Where did they last live together?

Day Month Year

When did they last live together?

How did they become separated?

Attach a completed form 681 Refugee and Special Humanitarian Proposal to this application (there is no charge
for lodging or processing form 681)
Your proposer should complete form 681 for lodgement with this visa application. Form 681 is available from
the Department’s website www.homeaffairs.gov.au
Attach a certified copy of the immediate family member’s Australian visa label or visa grant letter and evidence
of the relationship (eg. marriage certificate, birth certificate) if available
Provide details of humanitarian claims at Part G, Questions 25 – 37

842 (Design date 05/22) - Page 16 © COMMONWEALTH OF AUSTRALIA, 2022

20 Do any people included in this application have any other relatives residing in Australia?
No
Yes Give details Select
Details of the relative in Australia Details of the person in this application they are related to
Residence
Date of birth status in
Name Australia Address Given names Relationship to applicant
(use codes
Day Month Year below)

1.

2.

3.

4.

5.

If you need more space, please attach a separate page with the details

21 Do any people included in this application have any other past or present links to Australia?
No
Yes Indicate the types of links and give details
Links: Education Employment Business Friend Other

Details

‘Residence status in Australia’ codes

C = Citizen
PR = Permanent resident
TR = Temporary resident
S = Student
V = Visitor/Tourist
I = Illegal resident
U = Unlawful non-citizen
O = Other – give details on a separate page

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 17

 Part F – Background information A3 Given names

Does this person have a travel or identity document?

22 Give details of any valid travel documents (eg. passports) or identity
cards/documents held by all people included in this application No Attach a statement explaining what happened
to your documents
Note: If you do not have any documents, please explain why – do not
obtain fraudulent documents. Yes Give details Select
Type of document
A1 Main applicant (use codes below)
Passport number
Do you have a travel or identity document? (or document number)
No Attach a statement explaining what happened Country of issue
to your documents
Day Month Year
Yes Give details Select Date of issue
Type of document
(use codes below)
Date of expiry
Passport number
(or document number) Issuing authority/place of issue as shown in passport (or other document)
Country of issue
Day Month Year

Date of issue
A4 Given names
Date of expiry
Issuing authority/place of issue as shown in passport (or other document) Does this person have a travel or identity document?
No Attach a statement explaining what happened
to your documents
Yes Give details Select
Type of document
Other applicants (use codes below)

A2 Given names
Passport number
(or document number)
Does this person have a travel or identity document? Country of issue
No Attach a statement explaining what happened Day Month Year
to your documents
Date of issue
Yes Give details
Select
Type of document Date of expiry
(use codes below)
Issuing authority/place of issue as shown in passport (or other document)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue A5 Given names

Date of expiry Does this person have a travel or identity document?

Issuing authority/place of issue as shown in passport (or other document) No Attach a statement explaining what happened
to your documents
Yes Give details Select
Type of document
(use codes below)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue

Date of expiry
Issuing authority/place of issue as shown in passport (or other document)
‘Type of document’ codes
P = Passport
UN = UN Convention travel document or Titre de voyage
A = Alien/Asylum Registration Card
CI = Certificate or document of identity
S = Seafarer identity document
NIC = National identity card
842 (Design date 05/22) - Page 18 © COMMONWEALTH OF AUSTRALIA, 2022
 A6 Given names

Does this person have a travel or identity document?

No Attach a statement explaining what happened
to your documents
Yes Give details
Select
Type of document
(use codes below)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue

Date of expiry
Issuing authority/place of issue as shown in passport (or other document)

A7 Given names

Does this person have a travel or identity document?

No Attach a statement explaining what happened
to your documents
Yes Give details
Select
Type of document
(use codes below)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue

Date of expiry
Issuing authority/place of issue as shown in passport (or other document)

If you need more space, please attach a separate page with the details
Attach certified copies of the travel documents and identity
documents, if available

‘Type of document’ codes

P = Passport
UN = UN Convention travel document or Titre de voyage
A = Alien/Asylum Registration Card
CI = Certificate or document of identity
S = Seafarer identity document
NIC = National identity card
© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 19
23 Has any person included in this application applied to migrate to another country, or applied for refugee resettlement or asylum in any country?
No
Yes Give details

Family and given names Type of application

Date of application Application approved?
(If all persons included in this application, Which country? (eg. refugee resettlement,
write ‘ALL’) Day Month Year migration, asylum etc.) No Yes Not decided

If you need more space, please attach a separate page with the details

24 For EACH person included in this application list every address where they have lived during the last 10 years
Date you started to live
Given names of people included in this application
Address where you are living now at this address
who live at this address (if all, write ‘ALL’)
Day Month Year

Town Country

Period at this address Given names of people included in this application

Previous addresses
Month Year who live at this address (if all, write ‘ALL’)
1. From

To

Town Country

2. From

To

Town Country

3. From

To

Town Country

4. From

To

Town Country

5. From

To

Town Country

Attach certified copies of any visas/residence permits held by your family

842 (Design date 05/22) - Page 20 © COMMONWEALTH OF AUSTRALIA, 2022

 Part G – Humanitarian claims
• Your application will be assessed against the following 4 factors:
– the degree of persecution or discrimination to which you are subject in your home country
– the extent of your connection with Australia
– whether or not there is any suitable country available, other than Australia, that can provide for your settlement and protection from discrimination
– the capacity of the Australian community, or in the case of a Community Support Program application, your Approved Proposing Organisation, to
provide for the permanent settlement of persons such as you in Australia.
All applicants should include as much information as possible about these factors.
• Not all applicants are interviewed.
• Your answers should pay special attention to what happened to you and your family, not to the general situation in the country you fear returning to.
• When answering, you should tell us everything about why you and your family think you should be considered for entry to Australia under the Humanitarian
Program.
• In answering these questions, you should tell us if you think any incidents you mention are because of:
– your race
– your religion
– your nationality
– your membership of a particular social group
– your political opinion
– other reasons.
• You should provide as much information as possible relating to dates, locations, etc in respect of any incidents you mention.

25 For ALL the people included in this application list the ethnic group to which they belong, their religion and any political party/group to which they belong
Membership of political party/group
Given names Ethnic group or clan Religion (if any)
(if any)

A1 Main applicant

Other applicants
A2

A3

A4

A5

A6

A7

If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 21
26 What is the name of the country you fear living in or returning to?

27 Have you left the country you fear living in?

No
Yes Date you left
Day Month Year

28 Why do you fear living in or returning to the country you listed at Question 26?
Your answer should pay special attention to what happened to you, not the general situation in that country.

If you need more space, please attach a separate page with the details

842 (Design date 05/22) - Page 22 © COMMONWEALTH OF AUSTRALIA, 2022

29 If you have left the country you fear, how did you leave?
Legally Give details of your exit permit

Illegally Describe how you arranged to leave illegally

30 What do you believe may happen to you, or the people included in your application, if you were to return to or continue living in that country?
You should give full details of what you think may happen to you and reasons why that would happen

If you need more space, please attach a separate page with the details

31 Who do you think may harm or mistreat you if you continue living in or go back to that country?

If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 23
32 Do you think the authorities of that country can and will protect you if you continue living in or return to that country?
No Please explain why
Yes

33 Did you travel through, or stay, in any other countries before arriving in the country where you are now living?
No
Yes Give details including length of stay and dates
Date
Country From To
Day Month Year Day Month Year

34 Has this application been lodged because the United Nations High Commissioner for Refugees (UNHCR) referred you to Australia for resettlement?
No
Yes Attach a full copy of your UNHCR Resettlement Registration Form (RRF)

35 Has any person included in this application served in a military organisation (army/airforce/navy) or in a paramilitary organisation?
No
Yes Give details

1. Given name 2. Given name

Country served Country served

Name of military/paramilitary organisation Name of military/paramilitary organisation

Rank in this Rank in this

organisation organisation
Day Month Year Day Month Year
Dates of Dates of
membership From membership From
of this of this
organisation To organisation To
Why did this person leave this organisation? Why did this person leave this organisation?

If you need more space, please attach a separate page with the details
Attach certified copies of any discharge papers if available

842 (Design date 05/22) - Page 24 © COMMONWEALTH OF AUSTRALIA, 2022

36 Has any person included in this application ever lived in a refugee camp, collective accommodation centre for refugees, or detention centre?
No
Yes Give details
Given names of people included in this
Who ran the Dates lived there
Name of camp/centre Location application who lived there
camp/centre?
Day Month Year (if all, write ‘ALL’)

1. From

To

2. From

To

3. From

To

4. From

To

5. From

To

6. From

To

If you need more space, please attach a separate page with the details

37 If selected for an interview about your application, will you need an interpreter?
No
Yes Which language(s)?

If you are selected for an interview we will advise you if you are required to provide your own interpreter

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 25

 Part H – Employment history
38 For EACH person included in this application, list all the jobs that they have had in the last 15 years and show any periods of unemployment
For each person, start with the latest period of employment and work backwards
Dates of employment
Name of employer Location of employer Type of business Occupation and main duties
Day Month Year

A1 Main applicant

From

To

From

To

From

To

From

To

From

To

From

To

Other applicants
A2 Name

From

To

From

To

From

To

From

To

From

To

A3 Name

From

To

From

To

From

To

A4 Name

From

To

From

To

From

To

842 (Design date 05/22) - Page 26 © COMMONWEALTH OF AUSTRALIA, 2022

(Question 38 continued)
Dates of employment
Name of employer Location of employer Type of business Occupation and main duties
Day Month Year

A5 Name

From

To

From

To

From

To

From

To

A6 Name

From

To

From

To

From

To

From

To

A7 Name

From

To

From

To

From

To

From

To

Name

From

To

From

To

From

To

Name

From

To

From

To

From

To

If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 27
 Part I – Language and education
39 For EACH person included in this application, give details of their language Select
How well this person
Given names Main language spoken Other languages spoken speaks English
(insert code from below)

A1 Main applicant
Other applicants
A2

A3

A4

A5

A6

A7

If you need more space, please attach a separate page with the details

40 For EACH person included in this application, give details of their education
Highest educational
Primary school Secondary school Post-secondary education qualification obtained
Given names
(eg. school certificate, electrician
Day Month Year Day Month Year Day Month Year certificate, BA, PhD)

A1 Main applicant From From From

To To To

Other applicants
A2 From From From

To To To

A3 From From From

To To To

A4 From From From

To To To

A5 From From From

To To To

A6 From From From

To To To

A7 From From From

To To To

From From From

To To To

From From From

To To To

If you need more space, please attach a separate page with the details
English language codes
1 = Very well (eg. can speak English with little hesitation and few errors in most situations)
2 = Well (eg. can speak English well enough to deal with basic social and work situations)
3 = Not well (eg. can speak only a little English)
4 = Not at all

842 (Design date 05/22) - Page 28 © COMMONWEALTH OF AUSTRALIA, 2022

 Part J – Health • undergone any military/paramilitary training,
been trained in weapons/explosives or in the
41 Have you, or any other person included in this application, undergone a manufacture of chemical/biological products? No Yes
health examination for an Australian visa in the last 12 months? • been involved in people smuggling or people
No trafficking offences? No Yes
Yes Give details (including HAP ID if available) • been removed, deported or excluded from any
country (including Australia)? No Yes
• overstayed a visa in any country (including
Australia)? No Yes
• had any outstanding debts to the Australian
Government or any public authority in
Australia? No Yes
If you answered ‘Yes’ to any question at Question 42, give details,
including the date of the charge, the outcome and any penalty imposed.
Part K – Character Also attach court documents (for example sentencing remarks or court
transcripts).
42 For ALL persons included in this application answer the following Where relevant, provide a copy of all declared orders (for example, any
questions regarding their character, including past criminal activity, domestic or family violence orders, child protection orders, or orders that
spent convictions and other serious conduct. prohibit the applicant from having contact with another person for their
Have you, or any other person included in this application ever: personal protection). You are only requested to declare an order where
the applicant is the respondent or subject of the order. You are not asked
• been charged with any offence that is
to declare an order where the applicant is the person requiring personal
currently awaiting legal action? No Yes
protection.
• been convicted of an offence in any country
(including any conviction which is now
removed from official records)? No Yes
• been charged or convicted of a family or
domestic violence offence or any similar
related offence? No Yes
• been the subject of a domestic or family
violence order, or any other order, of a tribunal
or court or other similar authority, for the
personal protection of another person? No Yes
• been the subject of an arrest warrant or
Interpol notice? No Yes
• been found guilty of a sexually based offence
involving a child (including where no
conviction was recorded)? No Yes
• been named on a sex offender register? No Yes
• been acquitted of any offence on the grounds
of unsoundness of mind or insanity? No Yes
• been found by a court not fit to plead? No Yes
• been directly or indirectly involved in, or
associated with, activities which would
represent a risk to national security in
Australia or any other country? No Yes
• been charged with, or indicted for: genocide,
war crimes, crimes against humanity, torture,
slavery, or any other crime that is otherwise of
a serious international concern? No Yes
• been associated with a person, group or
organisation that has been/is involved in
criminal conduct? No Yes
• been associated with an organisation engaged
in violence or engaged in acts of violence
(including war, insurgency, freedom fighting,
terrorism, protest) either overseas or in
Australia? No Yes
• served in a military force, police force, state
sponsored/private militia or intelligence
agency (including secret police)? No Yes
If you need more space, please attach a separate page with the details.

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 29

 Part L – Assistance with this form Part M – Options for receiving
43 Did you receive assistance (other than clerical or translation assistance)
communications
in completing this form?
47 All communications about this application should be sent to:
No Go to Part M (Tick one box only)
Yes Please give details of the person or organisation who
Myself
assisted you
OR
Title: Mr Mrs Miss Ms Other
Proposer All communications will be sent to the proposer
Family name only provided in form 681.
Note: If you are applying in the Community
Given names OR Support Program, including a completed
form 1417, you should select this option.
Organisation
Myself and
Address proposer

OR
Authorised You should complete form 956A Appointment
Postcode recipient or withdrawal of an authorised recipient

Telephone number or daytime contact OR

Country code Area code Number
Migration agent Your migration agent/exempt person should
Office hours ( ) ( ) complete form 956 Advice by a registered
OR migration agent/exempt person of providing
Mobile/cell immigration assistance
Exempt person

44 Is the person an agent registered with the Office of the Migration Agents
Registration Authority (Office of the MARA)?
No
Yes Go to Part M

45 Is the person/agent in Australia?

No Go to Part M
Yes

46 Did you pay the person/agent and/or give a gift for this assistance?
No
Yes

842 (Design date 05/22) - Page 30 © COMMONWEALTH OF AUSTRALIA, 2022

 Part N – Australian values statement
48 AUSTRALIAN VALUES STATEMENT
Signature
This statement must be signed by the main applicant and each person of main
aged 18 years or over who is included in this application.
I confirm that I have read, or had explained to me, information provided
applicant -
by the Australian Government on Australian society and values.
I understand that Australian society values: Signature of
• respect for the freedom and dignity of the individual; dependent
• freedom of religion (including the freedom not to follow a particular
applicant -
religion), freedom of speech, and freedom of association;
Name
• commitment to the rule of law, which means that all people are
subject to the law and should obey it;
Signature of
• parliamentary democracy whereby our laws are determined by
dependent
parliaments elected by the people, those laws being paramount and
overriding any other inconsistent religious or secular ‘laws’;
applicant -
• equality of opportunity for all people, regardless of their gender,
Name
sexual orientation, age, disability, race, or national or ethnic origin;
• a ‘fair go’ for all that embraces: Signature of
– mutual respect; dependent
– tolerance; applicant -
– compassion for those in need;
– equality of opportunity for all; Name
• the English language as the national language, and as an important
Signature of
unifying element of Australian society.
dependent
I undertake to conduct myself in accordance with these values of
Australian society during my stay in Australia and to obey the laws of
applicant -
Australia.
Name
I undertake to make reasonable efforts to learn the English language, if
it is not my native language. Signature of
I understand that, if in the future I meet the legal qualifications for dependent
becoming an Australian citizen and my application is approved, I will
need to pledge my loyalty to Australia and its people.
applicant -
Name

Signature of
dependent
applicant -
Name

Signature of
dependent
applicant -
Name

© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 31

 Part O – Biometrics declaration and
consent
Signature
49 BIOMETRICS DECLARATION AND CONSENT or mark of
This declaration and consent must be signed by the main applicant and applicant -
each accompanying person aged 16 years or over. Day Month Year
If I am requested or required to provide my fingerprints and facial image: Date
I consent to:
• the collection of my fingerprints and facial image; and Signature
or mark of
• if applicable, the collection of the fingerprints and facial image of partner
each accompanying person under 16 years of age. (if applicable) -
I declare that: Day Month Year
• I understand that my fingerprints and facial image and my Date
biographical information (and those of each accompanying person
under 16 years of age) held by the Department may be given to
Australian law enforcement agencies to help identify me and each Signatures of persons aged 16 years or over who are included in this
accompanying person, to help determine my eligibility and the application (if applicable)
eligibility of each accompanying person for grant of the visa applied
for, and for law enforcement purposes; and Signature
• I understand that my identifying information, including my facial or mark
image, and other personal information (and those of each
-
accompanying person under 16 years of age) may be disclosed to Day Month Year
the Department’s contracted service providers for the purposes of Date
establishing my (and each accompanying person’s) eligibility and
need for settlement services, and providing those services.
Signature
I consent to:
or mark
• the Department disclosing my identifying information, including my -
facial image, and other personal information (and those of each Day Month Year
accompanying person under 16 years of age) and its contracted
service providers for the purposes outlined above; Date
• Australian law enforcement agencies disclosing my biometric,
biographical and criminal record information (and that of each Signature
accompanying person under 16 years of age) to the Department for or mark
any of the purposes outlined above; and -
• the Department using the information obtained for the purposes of Day Month Year
the Migration Act 1958 or the Australian Citizenship Act 2007. Date

Signature
or mark
-
Day Month Year

Date

Signature
or mark
-
Day Month Year

Date

Signature
or mark
-
Day Month Year

Date

842 (Design date 05/22) - Page 32 © COMMONWEALTH OF AUSTRALIA, 2022

 Part P – Declaration WARNING: Giving false or misleading information is a serious offence.

Signature
Warning: The Migration Act contains a power to cancel a visa if a or mark of
person has made an incorrect statement in relation to their
application. If it is determined that you have concealed information,
applicant -
Day Month Year
such as an offence, your application to enter Australia may be
refused. If you have already been granted a visa and it is Date
subsequently discovered that you have concealed information, such
as an offence, your visa will be liable to cancellation and you may be Signature
refused entry to Australia. In the event that you have already entered or mark of
partner
Australia your visa will be liable to cancellation and, if cancelled, you
may be detained and removed from Australia. (if applicable) -
Day Month Year

Date
50 This declaration must be signed by you (the main applicant) and ALL
persons aged 18 or over included in this application.
Signatures of persons aged 18 years or over who are included in this
I declare that:
application (if applicable)
• the information I have supplied on and with this form is complete,
correct and up-to-date in every detail.
Signature
• I did not marry or enter a de facto relationship to become eligible for
or mark
entry to Australia. -
• I understand that if I have given false or misleading information, my Day Month Year
application may be refused, or, if a visa has been granted, the visa
may be cancelled and I could be removed from Australia. Date
• I understand that if I am granted a visa, any person not included in
this application will not have automatic right of entry to Australia by Signature
way of this application. or mark
• I undertake to inform the Australian Government of any material -
changes to my circumstances while my application is being Day Month Year
considered, or before I am immigration cleared. Date
(Note: Your visa may be cancelled and you could be removed if you
do not advise of changes in circumstances).
• I authorise the Australian Government to make any enquiries Signature
necessary to determine my eligibility for entry to Australia, and to use or mark
any information supplied in this application for that purpose. -
Day Month Year
• I understand that unless my qualifications have already been
recognised by an Australian assessing authority before my departure, Date
they may not be recognised after my arrival.
• I understand that it is my personal responsibility to assess my own
employment prospects in Australia and acknowledge that labour Signature
or mark
market conditions there can vary significantly from time to time and
between regions.
-
Day Month Year
• I understand that grant of a visa provides no guarantee of
employment once in Australia. Date
• I have read the information contained in form 1442i Privacy notice.
• I understand the Department may collect, use and disclose my Signature
personal information (including biometric information and other or mark
sensitive information) as outlined in form 1442i Privacy notice. -
• I understand that information collected in the visa process may be Day Month Year
disclosed to other agencies and contracted service providers for the Date
purposes of evaluating my settlement needs and providing
settlement support.
For applicants applying in the Community Support Program: Signature
or mark
• I understand that my Approved Proposing Organisation will be
lodging this application on my behalf.
-
Day Month Year
• I understand that the information that I provide in this form may be
shared with my Approved Proposing Organisation and that my Date
Approved Proposing Organisation may also share this information
with any Supporting Community Organisations it works with in order We strongly advise that you keep a copy of your application
to provide services to help me settle in Australia. and all attachments for your records.

Important: If your circumstances change after you lodge this application (eg. you change your address, marry or become engaged to be married, or have
a baby), you must notify the office where you lodge this application. If your application is supported by a proposal form 681 Refugee and special
humanitarian proposal or form 1417 Community Support Program Proposal by Approved Proposing Organisations and your proposer’s circumstances
change after you have lodged this application, you should also notify the office where you lodge this application.
© COMMONWEALTH OF AUSTRALIA, 2022 842 (Design date 05/22) - Page 33
 Part Q – Document checklist Question Document Attached?
Q22 Certified* copies of travel documents and/or
This checklist is provided to help you submit a complete, decision-ready identity cards held by any person included in
application. If you do not have any of the requested documents (originals this application (if available)
or certified* copies) listed below, please provide an explanation as to OR
why you no longer have these documents.
A statement explaining why you have no
travel/identity documents
UNDER NO CIRCUMSTANCES SHOULD YOU SUBMIT FALSE
Q24 Certified* copies of any visas/residence
DOCUMENTS
permits held by any person included in this
application (if available)
51 Have you attached the following documents?
Q28 A detailed written statement (in English),
Question Document Attached? clearly explaining the reasons why you fear
Two (2) recent passport size photographs of living in or returning to your home country
each person included in your application, Q34 If you have been referred for resettlement by
with the full name of the person written the UNHCR, a full copy of your UNHCR
on the back of each photograph Resettlement Registration Form (RRF)
Q2 & 3 Evidence of the identity of each person Q35 Certified* copies of any discharge papers
included in this application (eg. certified* (if available)
copies of birth certificates, marriage
certificates, passport, national identity card
etc.), if available • If you have attached additional pages with answers, each page
Evidence of registration with any international must be marked with the question number it refers to, and
Q4
organisation dealing with refugees signed and dated by each person aged 18 years or over who is
(eg. UNHCR), if applicable included in this application.
Certified* copies of previous marriage/divorce • Please ensure you, your partner and persons aged 18 years or over
Q9
papers, or death certificates (if applicable) who are included in this application have signed the Declaration at
Part P.
Q10 Certified* copies of child custody papers
(if applicable) • If you do not provide all the necessary documents, or you have not
provided an adequate explanation why you cannot provide these
Q11 Certified* copies of adoption papers or a documents, a decision may be made on the information you have
written statement which explains the provided. It is in your interest to support your application with as
circumstances of adoption (if applicable) much information as possible at the time of lodging this application.
Q18 If your entry to Australia is being proposed by • You must lodge your Class XB visa application at the relevant office
a person or organisation in Australia, attach a of the Department responsible for visa applications from your country
fully completed form 681 completed by your of residence. To find out which office of the Department you need to
proposer lodge your application with, refer to the Department’s website at
OR www.homeaffairs.gov.au
If your entry to Australia is being proposed by Note: Certain applicants must lodge their application in Australia (see
an Approved Proposing Organisation under ‘Where can you lodge this application?’ on page 3).
the Community Support Program, attach a
fully completed form 1417 completed by your
Approved Proposing Organisation
Q19 If you are applying under the ‘split family’
provisions for immediate family members,
please attach:
a certified* copy of your proposer’s visa
evidence of the relationship with your
proposer (eg. a certified* copy of marriage or
birth certificate)
A form 681 completed by your immediate
family member in Australia who is proposing
you
Note: If applying under ‘split family’ provisions,
form 681 must be lodged with the form 842 at
the time you submit this application

* In Australia, copies of documents must be certified as true copies of the original

by a Justice of the Peace, Commissioner for Declarations, or a person before
whom a Statutory Declaration may be made under the Statutory Declarations
Act 1959.
* Outside Australia, copies of documents must be certified by a person who is the
equivalent of a Justice of the Peace or Commissioner for Declarations in the
country where the documents are being certified.
842 (Design date 05/22) - Page 34 © COMMONWEALTH OF AUSTRALIA, 2022