2 Were you living together at the time of death of the member? Yes No
(a) If 'Yes', for how long? ________________________________
Where did you live together? (address) ________________________________
If renting, in whose name was the property rented? ________________________________
If owned, in whose name is the title held? ________________________________
(b) Why were you living together?
Because of our special relationship? Yes No
Sharing accommodation for convenience (e.g. flatmates)? Yes No
Providing a paid carer service (e.g. assistance with mobility,
personal hygiene to the deceased? Yes No
Other reasons? (please describe) ________________________________
(c) If you were not living together at the time of death (although you did so previously) what was
the reason for not living together?
Holiday Visiting relatives Work commitments (since ___/___/______)
Disability (complete Question 5) Other (describe) _________________________
(d) If you were not living together at the time of death (although you did
so previously), did both of you intend to resume living together? Yes No
If 'Yes', when did you expect to be re-united? _________________________
Is there any evidence to support that both of you intended to resume
living together? (e.g. letters written by the deceased or given by close
associates etc.) If so, please provide copies or affidavits. Yes No
3 Did one or each of you provide the other with financial support? Yes No
(a) If 'Yes', what financial support was provided, and by whom?
The deceased contributed financial support by paying part or all of the
rent / mortgage / rates / other expenses of living together? Yes No
You contributed financial support by paying part or all of the rent /
mortgage / rates / other expenses of living together? Yes No
(If yes, attach documents to support this – eg rent receipts, bank statements)
If either the deceased or you provided financial support to each other in other ways, state
what that financial support was and attach any supporting documents.
(b) If 'No', what was the reason for not providing financial support?
Because one or each of us suffered from a disability? Yes No
(Provide details of the disability under Question 5 below)
Other reasons? (please describe) Yes No