Statement of Social and Financial Circumstances (Form CS2)

Rule 6(2) of the Workers Compensation and Injury Management Conciliation Rules 2024 (WA) requires an application for conciliation to include a statement of the worker's financial circumstances and reasonable financial needs where it seeks additional income compensation (s 52 of the Workers Compensation and Injury Management Act 2023), a standard increase in the medical and health expenses general limit (s 77), or an increase for special expenses (s 78). The statement must be accompanied by documentary evidence (r 6(3)). Each of those sections requires the decision-maker to have regard to the worker's social and financial circumstances and reasonable financial needs. CS2 is WorkCover WA's form for the statement, made as a statutory declaration under the Oaths, Affidavits and Statutory Declarations Act 2005 (WA).

When you need it

• You are applying for conciliation for additional income compensation under s 52, for example where income compensation paid exceeds 75% of the general limit and you are permanently totally incapacitated.
• You are seeking a standard increase in the medical and health expenses limit under s 77.
• You are seeking a special increase for special expenses under s 78. That section has its own preconditions, including at least 15% whole of person impairment and a 5-year limit (s 78(3) and (6)).

1. 1

   Section A - application details

   Enter the case number if known, the applicant and the respondent, and tick who is lodging (worker, worker representative, dependant, dependant representative or other).

2. 2

   Section B - declarant details

   Give the full name, address and occupation of the person making the declaration.

3. 3

   Dependants (Q6)

   List the people wholly dependent and partially dependent on you, with their ages.

4. 4

   Assets and liabilities (Q7, Q8)

   For you and your partner separately, give values for real estate, vehicles, bank accounts, shares and super, business interests and other assets, then mortgages, loans and other debts, and total each column.

5. 5

   Weekly income and expenses (Q9, Q10)

   Give weekly after-tax income from each source for you and your partner, including workers compensation payments and pensions, and weekly expenses item by item, from housing and utilities to medical, transport, schooling and insurance.

6. 6

   Supporting documents (Q11)

   List and attach the documents that support items 6 to 10, such as bank statements, payslips, loan statements and bills. Rule 6(3) requires documentary evidence.

7. 7

   Declaration (Q12)

   Sign in front of an authorised witness, who signs and adds their name and qualification. Page 5 lists who can witness in WA, elsewhere in Australia and overseas. Do not sign until you are with the witness.

• Lodge CS2 with the Application for Conciliation (CS1); the form says it must be lodged with that application (r 6(2)).
• A worker represented by a legal practitioner or authorised agent must lodge through WorkCover WA Online (r 26). An unrepresented worker is EDS exempt (r 27) and can also lodge by email to conciliation@workcover.wa.gov.au, in person at 2 Bedbrook Place, Shenton Park WA 6008, or by post to the Workers Compensation Conciliation Service (r 28).
• The Director gives the other parties a copy of the application and the documents lodged with it (r 8(1)).

• Be accurate. It is a statutory declaration, and the declaration states that making a false declaration is an offence. Giving false or misleading information to a dispute resolution authority is also an offence under s 388 of the Act.
• Attach evidence for each figure. A statement without documents does not meet r 6(3).
• For arbitration, WorkCover WA publishes a separate form, AS4 Statement of Financial Circumstances.