2015 Individual Income Tax return submission to H & R BLOCK DARWIN

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1 Tax File Number Are you an Australian resident? YES/NO/UNSURE VISA Name: Mr/Mrs/Ms/Miss Has your name changed since last return? NO/YES (Previous name ) Date of birth / / Postal address: Residential address (if different from address above.) Telephone: (H) (W) (M) Occupation:.. (If Applicable) Spouse/Partner Name: DOB income.. Children Name DOB income..dob income..dob income..dob income.

2 Your Bank Details for Deposit of Refund: BSB ACCOUNT NO ACCOUNT NAME: Please Note: Providing incorrect bank details could result in the refund not being able to be recovered. If your refund is returned to our Trust Account an additional fee of $30 will apply for reissuing your refund to the correct bank account. Salary or Wages (number of jobs/summaries for the year) Please attach Any income from centrelink? (allowances or pensions) Lump sum payments? Bank interest received? Dividends received? Did you sell any shares? Did you sell any assets? Received any foreign income? Do you have investment rental property? (will need to supply you a schedule) Did you receive any other income?

3 DEDUCTIONS: Work related car expenses ( are you required to use your vehicle for work?) Do you have a log book?( If so we need copy of records) If not, did you keep record of kms you used your vehicle c If you estimated more than 5,000kms we can use 12% of the cost of vehicle $ Or 1/3 of actual expenses Did you travel for conferences etc (will require more information from you ) For your occupation are you required to purchase Protective clothing /wear Uniforms Laundry and maintenance /repairs Dry cleaning _ Did you have any self education expenses? Not HELP/HECS Please add details in notes Home office expenses Computer and software Telephone/ mobile phone Tools and equipment if more than $300 Description & Date of Purchase

4 Subscriptions and union fees Journals/periodicals New items costing more that $300 Please include details in notes Sun protection products Seminars and courses not at an education institution Any other work related expenses Include details in notes Do you pay income protection (not part of super) Dividend deductions Gifts and donations Charity Name Cost of preparing your income tax return last year Did you make any personal super contributions What areas have you lived in the last financial year? Do you have net medical expenses (also for spouse and dependent children) over $2162? Are you entitled to Medicare levy exemption or reduction? For the 2013 income year were you and all of your dependants (including your spouse) covered by the appropriate health insurance hospital cover? If yes please provide the private health insurance end of year statement (we can t lodge your return without this information)

5 Did you become an Australian tax resident at any time during the 2013 year? Do you have a HECS/HELP liability of student financial supplement loan debt? Did a family trust or company distribute income to you for this financial year? Did you pay child support? I authorise H & R Block Darwin to access the ATO to be able to prepare my income tax return. I will either pay the upfront fee (if new client) of $169* by credit card or direct credit if requested or have the fee deducted from my refund starting at $199*or, In the event there is no refund I will pay the fee to H & R Block within 7 days of being notified. We may request more information before we complete your tax return. *This fee is based on a standard basic return without any investments/extra work Dated:.day of Signature of taxpayer.. Name: Additional Information: completed form to or Fax to

6 Electronic Lodgment Declaration (Individual) This declaration is to be completed where a taxpayer elects to use to Electronic Lodgment Service. It is the responsibility of the taxpayer to retain this declaration for a period of five years after the declaration is made; penalties may apply for failure to do so. Tax File Number (TFN) Year Name I declare that all the information in the return, including the supplement to the income tax return and schedule if applicable is true and correct, and I have shown all my income for tax purposes, including net capital gains, from sources in and out of Australia for the year of income. I have all the necessary receipts and/or other records, or expect to obtain the necessary written evidence within a reasonable time of lodgment of this tax return to support my claims for declarations, a tax rebates and Family Tax Benefit. I authorize my tax agent to electronically transmit my income tax return and/ or Family Tax Benefit tax claim or application for amendment. Important: tax law imposes heavy penalties for giving false or misleading information. Signature Electronic Funds Transfer Consent Date This declaration is to be completed when an Electronic Funds Transfer (EFT) of refund is requested and the transaction is being lodged through the Electronic Lodgment Services (ELS). This authorization will remain valid until the next income tax return/amendment is lodged or until the ATO receives new EFT instructions. The declaration must be signed by the taxpayer prior to the EFT details being transmitted to the ATO. If you provided account details last year and they have not changed, do not write them again. Signature Date Tax Agent :

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