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Tax file number declaration

This declaration is NOT an application for a tax file number. Please print neatly in BLOCK LETTERS and use a BLACK or DARK BLUE pen. Print X in the appropriate boxes. Please ensure you read all the instructions prior to completing this declaration.

ORIGINAL Tax Office copy

www.ato.gov.au

30920704

Section A – to be completed by PAYEE

1

Your tax file number (TFN)

OR I have made a separate application/enquiry to the Tax Office for a new or existing TFN.

refer to the cover for privacy information

Full-time

Part-time

Casual

Labour

employment

employment

employment

hire

7

On what basis are you paid? (Select one only.)

Superannuation pension or annuity

OR I am claiming an exemption because I am under 18 years of age and do not earn enough to pay tax.

8

Are you an Australian resident for tax purposes?

Yes

No

If ‘No’, you must answer ‘No’ at question 9.

2

OR I am claiming an exemption because I am a pensioner.

Do you authorise your payer to give your TFN to the trustee of your superannuation fund or to your retirement savings account (RSA) provider?

Yes

No

9

Do you wish to claim the tax-free threshold from this payer? NOTE: If you have more than one source of income and currently claim the tax-free threshold from another payer, DO NOT claim it now.

Yes

No

If ‘No’, you must answer ‘No’ at questions 10 and 11 unless you are a non-resident claiming a Senior Australians tax offset or a zone tax offset respectively.

3 Your name Surname or family name

Title:

Mr

Mrs

Miss

Ms

10

Are you claiming a reduced rate of withholding for either family tax benefit or Senior Australians tax offset?

Yes

If ‘Yes’, obtain a Withholding declaration from your payer, but only if you are claiming the tax-free threshold from this payer. If you have more than one payer, see page 3 of the instructions.

No

First given name

11

Are you claiming a zone, dependent spouse or special tax offset?

Yes

If ‘Yes’, obtain a Withholding declaration from your payer.

No

Other given names

4

If you have changed your name since you last dealt with the Tax Office, show your previous family name

12

(a) Do you have an accumulated HECS debt? Yes If ‘Yes’, your payer will withhold additional amounts to cover your anticipated compulsory repayment(s).

No

(b) Do you have an accumulated Financial Supplement debt?

Yes

If ‘Yes’, your payer will withhold additional amounts to cover your anticipated compulsory repayment(s).

No

5

Your date of birth

DAY

MONTH

YEAR

13

Do you wish to claim entitlements to a deductible amount or tax offset for an annuity or superannuation pension?

6 Your home address in Australia

Yes

If ‘Yes’, your superannuation provider or the organisation that sold you your annuity will work out your entitlement.

No

Declaration:

I declare that the information I have given is true and correct.

Signature

Suburb or town

There are penalties for deliberately making a false or misleading statement.

DAY

MONTH

YEAR

State

Postcode

Date

Section B – to be completed by PAYER

1

Australian business number (ABN)

Branch number

4

If you have ceased making payments to this payee, print X in this box.

[or withholder payer number (WPN) if not in business (if applicable) (see notes on page 4)]

5

Contact person

If you have not been issued with an ABN or WPN, or you cannot find the ABN or WPN issued to you, phone 13 28 66.

Date ABN or WPN requested

DAY

MONTH

YEAR

Daytime telephone during business hours

Area Code

2

Registered business or trading name (or individual name if not in business)

Signature of payer

Please note: Penalties apply where you fail to forward the original to the Tax Office.

DAY

MONTH

YEAR

Australian Taxation Office

Australian Taxation Office

PO Box 795 Albury NSW 2640

PO Box 9004 Penrith NSW 2740

3

Business address

Return completed original Tax Office copy to:

For WA, SA, NT, Vic and Tas

For NSW, Qld and ACT

NAT 3092-7.2004

Please estimate the time taken to complete section B.

mins

TAXPAYER-IN-CONFIDENCE (when completed)

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