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.
Section A – to be completed by PAYEE
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
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.
Are you an Australian resident for tax purposes?
If ‘No’, you must answer ‘No’ at question 9.
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?
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.
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
Are you claiming a reduced rate of withholding for either family tax benefit or Senior Australians tax offset?
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.
First given name
Are you claiming a zone, dependent spouse or special tax offset?
If ‘Yes’, obtain a Withholding declaration from your payer.
Other given names
If you have changed your name since you last dealt with the Tax Office, show your previous family name
(a) Do you have an accumulated HECS debt? Yes If ‘Yes’, your payer will withhold additional amounts to cover your anticipated compulsory repayment(s).
(b) Do you have an accumulated Financial Supplement debt?
If ‘Yes’, your payer will withhold additional amounts to cover your anticipated compulsory repayment(s).
Your date of birth
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
If ‘Yes’, your superannuation provider or the organisation that sold you your annuity will work out your entitlement.
I declare that the information I have given is true and correct.
Suburb or town
There are penalties for deliberately making a false or misleading statement.
Section B – to be completed by PAYER
Australian business number (ABN)
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)]
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
Daytime telephone during business hours
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.
Australian Taxation Office
Australian Taxation Office
PO Box 795 Albury NSW 2640
PO Box 9004 Penrith NSW 2740
Return completed original Tax Office copy to:
For WA, SA, NT, Vic and Tas
For NSW, Qld and ACT
Please estimate the time taken to complete section B.
TAXPAYER-IN-CONFIDENCE (when completed)