Salary Packaging Application Forms

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1 Salary Packaging Application Forms The following forms for salary packaging of superannuation and/or other benefits follow. If packaging superannuation only, you should use the forms from the Superannuation Salary Packaging Booklet. 1. Salary Packaging Application This is the main document, which must be completed for packaging to commence. 2. Financial Adviser Form This must be included with your application when packaging benefits other than superannuation only. Your adviser must sign this document and include his/her registration or adviser number. 3. Salary Packaging Participation Agreement This document must be included with your application. RemServ can arrange for the employer signature, but you must ensure that you sign and date this document before sending. Additional Documents 4. Direct Debit Reimbursement Request For benefits that you pay by direct debit where reimbursements are required. One form for each benefit paid in this way should be included with your application as applicable. 5. Expense Payment Benefit Declaration Include this declaration if packaging: Airport Lounge Membership Briefcases, calculators, tools of trade, and protective clothing Home Office Expenses Mobile Phone Expenses Professional Memberships and Subscriptions Work Related Travel 6. BP Fuel Card Confirmation of Details This form is for use where vehicle details are not available at the time of application. 7. Landlord Declarations Include one of these declarations if packaging home rental expenses where other forms of substantiation are not available. Your landlord will need to complete a portion of the declaration. 8. Third Party Authorisation Use this form to authorise your partner, associate or financial adviser to act on your behalf. 9. Payments/Reimbursement Claim Form This form is to be used for payment requests. Additional copies of this and other administration forms can be found on the RemServ web site. ª This work is copyright. It may be reproduced in whole or in part for Queensland Government purposes subject to the inclusion of any acknowledgement of the source and no commercial usage or sale. Reproduction for the purposes other than those indicated above, requires the prior written permission from. Requests and enquiries concerning reproduction and rights should be addressed to, GPO Box 424, Brisbane QLD Privacy Policy : RemServ is committed to adhering to National Privacy Principles (NPP) 1-10 as defined by the Office of the Federal Privacy Commissioner in accordance with the Privacy Act Version 3.10 Page 1

2 State Library of Queensland Contact Details GPO Box 424 Brisbane QLD 4001 Salary Packaging Application Form Enquiries: Confidential Title Given Names Surname Preferred Name (if different) Date of Birth / / Gender: M / F Telephone: Work ( ) Home ( ) Work Fax ( ) Home Fax ( ) Mobile Home Address: Suburb Post Code Home Postal Address (if different from above): Suburb Post Code Name of Employer: Work Address : Suburb Post Code Position Title: Work Personal Address for forwarding of correspondence/statements: Home [ ] Business [ ] Payroll Details Payroll ID Number Payroll Office (where applicable) Corporate Office/Statewide Service/District (where applicable) Pay Status (circle one) Permanent: Full Time / Part Time Contract/Temporary: Full Time / Part Time Statements to be sent: Monthly [ ] Quarterly [ ] Annually [ ] via Internet only [ ] Please contact (tick one) [ ] Me [ ] My financial adviser if any clarification is required for my application. Please include a Third Party Authorisation form if you wish your adviser to act on your behalf on an ongoing basis. Acceptance I hereby authorise the payroll officer to make the amendments or commencements to my pre and or post tax salary, as indicated, with effect from the next available pay fortnight, until further notice. I confirm that the total of all benefits packaged (including superannuation) is 50% or less of my fortnightly superannuable salary. I understand the figures that I have represented here will be processed by RemServ and submitted to my pay office. Name (printed)... Pay roll office :... Signature... Date..... Office use Only Standard percentage Defined [ ] Accumulation [ ] State [ ] % Additional voluntary $ Pre tax $ Post tax $ Application continues on the next page Page 2

3 Superannuation If packaging superannuation as the only benefit, please refer to the Superannuation Salary Packaging Booklet and submit the QSuper salary packaging forms from that booklet. If you wish to package your standard superannuation contribution go to Part A. If you wish to package additional voluntary superannuation contributions to Part B. *If you are unsure which QSuper account you have, or have any other queries contact Qsuper on Part A. Standard Contributions to Superannuation Defined Benefit Account Please tick only ONE box for the standard percentage (either non gross up or gross up, NOT both) Reduced Rates Standard Rate Catch up Rates Only 2% 3% 4% 5% 6% 7% 8% Non Gross Up % Gross Up % 2.35% 3.52% 4.70% 5.88% 7.05% 8.23% 9.41% Catch up rates are only available for pre-approved Defined Benefit members catching up contributions after previously paying at a rate less than 5%. Selecting the gross up contribution amounts will ensure you receive the greatest end benefit, as you will have covered the 15% contributions tax. Accumulation Account Please tick only ONE box for the standard percentage Reduced Rates Standard Rate 2% 3% 4% 5% Non Gross Up % State or Police Account (please delete which does not apply) My contribution per fortnight should be: IMPORTANT: You must contact QSuper to obtain the correct contribution information for this section, as contribution rates differ on an individual basis. Rate must reflect that which is advised in writing by QSuper. % Part B Voluntary Contributions If you do not wish to make additional voluntary contributions, please leave this box blank and complete the rest of the application on the following page. I wish to make additional voluntary contributions from pre tax dollars. My voluntary contribution per fortnight should be: $ This form cannot be used to transfer between account types. If you don t know which account you are in, please refer to your most recent Annual Benefit Statement or contact QSuper before completing these forms. Application continues on the next page Page 3

4 TOTALS Please total all benefits packaged on the following pages, including the administration fee Total Amount per fortnight per year Total Amount from Pages 5-18 $ $ FBT provision amount (where applicable) TOTAL AMOUNT PACKAGED (This amount should exclude amounts for superannuation) $ $ I require post tax deductions to be contributed (ECM). The amount per fortnight is: Please note that post tax contributions should not be less than $20.00 per fortnight. $ Please complete this section if it applies to you. It is your responsibility to ensure that any additional fringe benefits are reviewed as part of your salary packaging as there are fringe benefit tax implications. I have non salary packaged fringe benefits (eg car or mobile phone provided by the employer). The Grossed Up Taxable Value (GUTV) per year (estimate) is: Bank Account for Reimbursements if applicable Bank / Credit Union Name Account in Name of Bank BSB : - Account : $ Please specify basis of calculations (are or are not based on 26 fortnights.) o Calculations are based on 26 fortnights in the year. o Calculations are based on fortnights. Application continues on the next page Page 4

5 ADMINISTRATION FEE PACKAGING FORTNIGHTLY ONLY Tick the administration fee applicable [ ] Administration fee $ no reportable benefits apply [ ] Administration fee $9.70 reportable benefits apply Total Cost per year Total Cost per fortnight v If you would prefer to pay the administration fee in full on commencement please completed the payment authority below. PAYMENT AUTHORITY FOR ANNUAL ADMINISTRATION FEE PAID UP FRONT [ ] Full reportable benefits $ cheque attached payable to [ ] Full reportable benefits $ money order attached payable to [ ] Non reportable benefits $ cheque attached payable to [ ] Non reportable benefits $ money order attached payable to [ ] Payment by credit card (please circle one) Bankcard Mastercard Visa Card Number Expiry Date / Cardholder s Name Cardholder s Signature Date / / This document will be a Tax Invoice for GST when you make the payment. Please make a COPY of this form when completed and keep as your tax invoice. GPO Box 424 Brisbane QLD 4001 ABN Application continues on the next page Page 5

6 Nominated Benefits Please nominate below the benefits you wish to package to and provide the relevant substantiation. Please show the expected payment amount and also the amount you will package to pay for each benefit, shown as a fortnightly and annual figure. Please specify if calculations are or are not based on 26 fortnights. Aged Care and Disability Costs Name of Aged Care /Disability Services Provider Payment Amount $ Option 1 - Irregular or single payments only. Option 2 Regular direct payment Payments to be made: Submit invoice for payment; or Submit the invoice and receipt for reimbursement. [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Submit invoice with your application for RemServ to pay directly to the supplier. Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Option 3 - Regular direct debit to be reimbursed. Please attach invoice and bank statement showing direct debits and the Direct Debit Reimbursement Request on page 36. Total amount to package per year Amount to package per fortnight Airport Lounge Membership [ ] I will submit the invoice for payment [ ] I will submit the invoice and receipt for reimbursement. The Expense Payment Benefit Declaration on page 37. Total amount to package per year Amount to package per fortnight Briefcases, Calculators, Tools of Trade and Protective Clothing [ ] I will submit the invoice for payment [ ] I will submit the invoice and receipt for reimbursement. The Expense Payment Benefit Declaration on page 37. Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 6

7 Car Parking Payment Amount $ Option 1 - Pay deduction to be reimbursed Provide two current pay slip to show this regular deduction for reimbursement. Option 2 - Irregular or single payments only. Submit invoice for payment; or Submit the invoice and receipt for reimbursement. Option 3 Regular direct payment to supplier Payments to be made: [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Submit invoice with your application for RemServ to pay directly to the supplier Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Total amount to package per year Amount to package per fortnight Application continues on the next page Page 7

8 Child Care Please tick one The child care provider is [ ] In house [ ] Non-employer owned Option 1 - Regular direct payment to supplier Payments to be made: [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Name of service provider : Lodgement Reference Code : Account Name: BSB : - Account Number: Amount to be paid to this account $ Submit copy of invoice with your application. Submit supplier letter or statement confirming account details if direct payment is required. Option 2 - Single Payment/Reimbursement Upon Request. Submit invoice for payment; or Submit the invoice and receipt for reimbursement. A copy of the invoice and bank statement showing the direct debit and the Direct Debit Reimbursement Request on page 36. Option 3 - Pay deduction or direct debit to be reimbursed [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only Payment Amount $ Provide current pay slip to show this regular deduction for reimbursement. Total amount to package per year for Amount to package per fortnight Child Care Declaration: I,... (Employee Name) understand that by salary packaging, I may be ineligible or have a reduced claim to the Child Care Benefit (CCB). Signed:... For more information regarding Child Care Benefit Call the Family Assistance Office on Visit internet site at Call Medicare on Date:. /.. /.. Application continues on the next page Page 8

9 Club/Association Membership Subscriptions (non work related) [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. Total amount to package per year for Amount to package per fortnight Disability / Income Protection Insurance 1. Name of Disability / Income Protection Insurer Account/Policy Number Payment Amount $ 2. Name of Disability / Income Protection Insurer Account/Policy Number Payment Amount $ Option 1 - Irregular or single payments only. Option 2 Regular direct payment Submit invoice for payment; or Submit the invoice and receipt for reimbursement. Payments to be made: [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Option 3 - Regular direct debit to be reimbursed. Submit invoice with your application for RemServ to pay directly to the supplier Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Please attach invoice and bank statement showing direct debit amounts and the Direct Debit Reimbursement Request on page 36. Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 9

10 Financial Adviser Fees Payment Amount $ Option 1 -Irregular or single payments only. Option 2 - Regular direct payment Payments to be made: Submit invoice for payment; or Submit the invoice and receipt for reimbursement. [ ] Fortnightly [ ]Monthly [ ] Quarterly Submit invoice with your application for RemServ to pay directly to the supplier Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Total amount to package per year for Amount to package per fortnight Health Insurance Please note that the amount you package must NOT include the 30% the Government pays as a rebate. 1.Name of Fund Membership Number Payment Amount $ 2.Name of Fund Membership Number Payment Amount $ Option 1 - Pay deduction to be reimbursed Provide two current pay slip to show this regular deduction for reimbursement. Option 2 - Irregular payments Option 3 - Regular direct payment Payments to be made: Submit invoice for payment; or Submit the invoice and receipt for reimbursement. [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Submit invoice with your application for RemServ to pay directly to the supplier. Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Option 4 Regular direct debit to be reimbursed Please attach a copy of your invoice/statement and complete the Direct Debit Reimbursement Request on page 36. Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 10

11 HECS Fees Payment Amount $ Option 1 Irregular or single payments only. Option 2 Regular direct payment Submit invoice for payment; or Submit the invoice and receipt for reimbursement. Payments to be made: HECS EFT Code: [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Submit University invoice or ATO remittance with your application Option 3 - Reimbursement Submit proof of payment to University or ATO with your application. Total amount to package per year for Amount to package per fortnight You must provide your 18- character HECS EFT code for direct payments. Your HECS EFT code is printed on the top right of your HECS information statement just below your tax file number. If you cannot find your HECS EFT code, ring the ATO on Make sure you provide the HECS EFT code accurately as it is used to correctly identify your account and the type of payment being made. If you request a voluntary repayment of $500 or more, you will receive a bonus of 15%. Note that the bonus is 15% of the payment that you make, not 15% of the outstanding debt. You will not receive a bonus on repayment amounts that exceed the balance of your HECS account. Application continues on the next page Page 11

12 Home Mortgage Option 1 Regular direct payment (may be to two accounts if applicable) Payment Frequency [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Upon Request [ ]There is a regular due date (eg on 15th of each month). Please give details: [ ]If weekly please specify day: Your application/contract number may not be your loan account number. Please check with your bank. Credit union or building society member number (may be different from account number): Name of bank or lending institution: Account Name: BSB : - Account Number: Amount to be paid to this account $ Name of bank or lending institution: Account Name: BSB : - Account Number: Amount to be paid to this account $ Copy of loan statement(s) or bank letter confirming loan account name(s) and number(s). The completed Loan Draw Down Declaration on the next page must be included if packaging. Option 2 Regular reimbursement for direct debit (may be to two accounts if applicable) Payment Frequency [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Upon Request [ ]There is a regular due date (eg on 15th of each month). Please give details: [ ]If weekly please specify day: If your direct debit will increase in the future, you will need to forward a new bank statement to substantiate the new amount. Credit union or building society member number (may be different from account number): Name of bank or lending institution: Account Name: BSB : - Account Number: Amount to be reimbursed to this account $ Name of bank or lending institution: Account Name: BSB : - Account Number: Amount to be reimbursed to this account $ Copy of the bank statement(s) for account shown above with bank account name and number showing the regular direct debit from the account and loan statement. Evidence of the account numbers of both accounts from the lending institution should be provided. BSB must be provided The completed Loan Draw Down Declaration on the next page must be included if packaging. Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 12

13 LOAN DRAW-DOWN DECLARATION I,... (Employee Name) advise that: a) I have a loan facility under which I am the recipient of loan funds by way of housing mortgage; b) This facility enables funds to be redrawn under various circumstances provided for in the applicable housing mortgage documentation; As a result, I hereby declare that where makes payment of any amount, under the salary package arrangements available to me, in satisfaction of any liability arising under the aforementioned housing mortgage, I will not seek to obtain a subsequent draw-loan of any funds so paid unless; i. Such funds are also used for a valid purpose which is itself available to me under the salary package arrangements associated with ; and ii. Sufficient documentation is provided to in order to substantiate such validity. Declarant: Signed:... Name:... Date:. /.. /.. Witness: Signed:... Name:... Date:. /.. /.. Application continues on the next page Page 13

14 Home Office Expenses [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. The completed Expense Payment Declaration on page 37. Total amount to package per year for Amount to package per fortnight for Mobile Phones (predominantly business) [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. [ ] Regular reimbursement of direct debit. Please attach copy of invoice and Direct Debit Reimbursement Request on page 36. A copy of invoice and Expense Payment Benefit Declaration on page 37. Total amount to package per year for this benefit Amount to package per fortnight Motor Vehicle Novated Lease Name of Financier Financier s address Capital Cost of Vehicle $ Lease Commencement Date: Estimated kilometres per year: Statutory fraction [ ] 7% [ ] 11% [ ] 20% [ ] 26% Lease Expiry Date: Registration Number (when available) Opening Odometer Reading (when available) Model: Make: Colour (when available): Due date: day of each month. Total amount payable to financier each MONTH $ Copy of finance schedule or quotation if provided and the Deed of Novation. Please forward the payment book if your financier requires payment using this method. Copy of financial adviser s worksheet/calculations If your novated lease agreement does not include fuel, registration and insurance, you must package this as a separate item and include the details in the next section. A fuel card will be issued to you. See the Novated Lease Salary Packaging Booklet for further details. [ ] I am packaging part of this payment post tax using the Employee Contribution Method (ECM). Application continues on the next page Page 14

15 Motor Vehicle Operating Costs for Novated Lease Registration [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. Total amount to package per year for Amount to package per fortnight Maintenance [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. Total amount to package per year for Amount to package per fortnight Fuel I am packaging a novated lease and will package a fuel card. [ ] Fuel card will be provided with my lease through the financier. [ ] I require a RemServ issued BP fuel card and will submit details below Total amount to package per year for Amount to package per fortnight Please supply me with a BP fuel card for the vehicle listed below. Fuel cards can only be issued where all required information is provided. Please submit the BP Fuel Card Confirmation of Details form when you have the required information if these details are not yet available. REGISTRATION NO: MAKE: MODEL: COLOUR: FUEL TYPE: STARTING ODOMETER READING: I understand that my BP fuel card is a credit card only and payment of the account is ultimately my responsibility. It is understood that Remuneration Services will undertake to pay my account as part of my salary packaging agreement. If at any time my salary packaged funds are insufficient to cover the amount due, it is agreed that Remuneration Services will pay the shortfall on my behalf and any amount paid will be reimbursed to Remuneration Services by me. It is further agreed and acknowledged that if at any time I cease salary packaging with Remuneration Services any amount owing on my BP fuel card may be paid by Remuneration Services out of my trust fund and if my trust fund is insufficient to clear the amount owing on my BP fuel card, any shortfall will be reimbursed to Remuneration Services by me. Signed:..... Date:.../.../... Name:... Application continues on the next page Page 15

16 Motor Vehicle Operating Costs for Novated Lease Cont... Insurance Name of Insurer: Payment Amount: $ Option 1 Irregular or Single payments only. Option 2 Regular direct payment to insurer Submit invoice for payment; or Submit the invoice and receipt for reimbursement. Payments to be made: [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Submit invoice with your application for RemServ to pay directly to the supplier. Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Option 3 Regular direct debit to be reimbursed Please attach copy of invoice and bank statement showing direct debits and Direct Debit Reimbursement Request on page 36. Total amount to package per year for Amount to package per fortnight Total amount to package per year for Amount to package per fortnight FBT Provision Amount Total amount to package per year for Amount to package per fortnight GST on ECM component Total Motor Vehicle Novated Lease and Novated Lease Operating Costs (inclusive of tax provisions) Total amount to package per YEAR Amount to package per FORTNIGHT Pre Tax Amounts Post Tax Amounts (ECM) Application continues on the next page Page 16

17 Motor Vehicle Operating Costs (not Novated Lease) Registration [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. Total amount to package per year for Amount to package per fortnight Maintenance [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. [ ] I will submit the tax invoice (s) for direct payment Total amount to package per year for Amount to package per fortnight Fuel [ ] I will submit the tax receipts for reimbursement. [ ] I will submit the tax invoice (s) for direct payment [ ] I require a fuel card and will submit the required information listed below Total amount to package per year for Amount to package per fortnight I wish to be supplied with a BP fuel card for the vehicle listed below Fuel Cards can only be issued where all required information is provided. Please use the BP Fuel Card Confirmation of Details form once you have the required information. REGISTRATION NO: MAKE: MODEL: COLOUR: FUEL TYPE: STARTING ODOMETER READING: I understand that my BP fuel card is a credit card only and payment of the account is ultimately my responsibility. It is understood that Remuneration Services will undertake to pay my account as part of my salary packaging agreement. If at any time my salary packaged funds are insufficient to cover the amount due, it is agreed that Remuneration Services will pay the shortfall on my behalf and any amount paid will be reimbursed to Remuneration Services by me. It is further agreed and acknowledged that if at any time I cease salary packaging with Remuneration Services any amount owing on my BP fuel card may be paid by Remuneration Services out of my trust fund and if my trust fund is insufficient to clear the amount owing on my BP fuel card, any shortfall will be reimbursed to Remuneration Services by me. Signed:..... Date:.../.../... Name:... Application continues on the next page Page 17

18 Motor Vehicle Operating Costs (not Novated Lease) Cont... Insurance 1.Name of Insurer: Insurance 2. Name of Insurer: Payment Amount: $ Payment Amount: $ Option 1 - Irregular or single payments only. Option 2 - Regular Direct payment to insurer Submit invoice for payment; or Submit the invoice and receipt for reimbursement. Payments to be made: [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Option 3 Regular direct debit to be reimbursed Submit invoice with your application for RemServ to pay directly to the supplier Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Please attach copy of invoice and bank statement showing direct debits and Direct Debit Reimbursement Request on page 36. Total amount to package per year for Amount to package per fortnight Notebook/ Laptop Computers, Electronic Diaries and Packaged Software Payment Amount $ Payments to be made: [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Option 1 - Single payments only. Option 2 Regular reimbursement of up-front purchase Submit invoice for payment; or Submit the invoice and receipt for reimbursement. Invoice and proof of payment Option 3 Regular direct payment to hire purchase / leasing provider Please submit invoice/ hire purchase/ lease payment details with your application. Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Option 4 Reimbursement of direct debit to hire purchase /leasing provider Please attach copy of invoice and bank statement showing direct debits and Direct Debit Reimbursement Request on page 36. Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 18

19 Personal Loan Repayments Name of Lender: Payment Frequency [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ]There is a regular due date (eg on 15th of each month). Please give details: Payment Amount $ Option 1 Personal Loan Payment is to be made directly to this account: Your application/contract number may not be your loan account number. Please check with your bank. Name of bank or lending institution: Account Name: Name of bank or lending institution: Account Name: Credit union or building society member number (may be different from account number): BSB : - Account Number: Serial Number (if Applicable Amount to be paid to this account $ BSB : - Account Number: Serial Number (if Applicable Amount to be paid to this account $ Option 2 Personal loan direct debit payment to be reimbursed Your application/contract number may not be your loan account number. Please check with your bank. Copy of loan statement or bank letter confirming loan account name and number or payment slip from the loan payment book showing account name and number. Name of bank or lending institution: Account Name: Name of bank or lending institution: Account Name: Credit union or building society member number (may be different from account number): BSB : - Account Number: Amount to be paid to this account $ BSB : - Account Number: Amount to be paid to this account $ Copy of the bank statement(s) for account shown above with bank account name and number showing the regular direct debit from the account. Copy of loan statement or bank letter confirming loan account name and number. Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 19

20 Private Travel [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. Total amount to package per year for Amount to package per fortnight for Professional Memberships/ Subscriptions [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. [ ] Regular reimbursement of direct debit. Please attach copy of invoice and Direct Debit Reimbursement Request on page 36. [ ] Reimbursement of payroll deductions provide two current payslips showing these deductions. The Expense Payment Declaration on page 37 must be included if packaging. Total amount to package per year for Amount to package per fortnight for Rental own home Name of Agent/ Landlord Agent/Landlord address Agent/Landlord contact telephone Payment Amount $ Regular payments to be made: [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Option 1 Pay rent directly to agent/landlord s account Client reference number if required by landlord. Account Name: BSB : - Account Number: Option 2 Home rental direct debit payment to be reimbursed Option 3 Direct payment to be reimbursed Letter on business letterhead from agent or a Landlords Declaration confirming account details Copy of lease agreement (must be current) Copy of the bank showing the regular direct debits from the account or a copy the the direct debit authority Copy of lease agreement (must be current), or a Landlord Declaration Copy of receipt Copy of lease agreement (must be current), or a Landlord Declaration Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 20

21 LANDLORD/AGENT DECLARATION RemServ reimburses your rental payment Use this form if you do not have a current formal tenancy agreement with your landlord or to provide other payment information in addition to your lease. I, (Tenants Name) of..... (Rental Property Address) Declare that the above property is rented from......under the rental tenancy act. (Landlord/Agent) I confirm that the details for reimbursement of rent are as follows: Bank / Credit Union Name Account in Name of Bank BSB : - Account : The reimbursement amount is to be $ per fortnight/month/quarter I understand that the rent will continue to be reimbursed up to the date shown above and that I will be required to confirm an extension of the rental arrangement in writing to RemServ if I require rent reimbursement payments to continue. I understand that any payment made to me by RemServ as a rent reimbursement will not comply with Australian Taxation Office salary packaging if I am not paying an equal or greater amount in rent to the landlord or agent. Signature:...Date:. /.. / LANDLORD OR AGENT TO COMPLETE I...., Phone number (Landlord/Agent Name) Declare that the abovenamed is currently residing in the rental property owned/managed by myself, at the abovenamed property. at (Rental Property Address) This rental arrangement is current up to (Date) Rent amount paid $... per fortnight/month/quarter Signature:...Date:... Witnessed this day of, 20 Signature of Witness (not employee) Name of Witness (please print) Application continues on the next page Page 21

22 LANDLORD/AGENT DECLARATION RemServ pays your rent direct to your landlord Use this form if you do not have a current formal tenancy agreement with your landlord or to provide other payment information in addition to your lease. I, (Tenants Name) of..... (Rental Property Address) Declare that the above property is rented from......under the rental tenancy act. (Landlord/Agent) The salary packaged contribution amount is to be $ per fortnight/month/quarter I understand that I am required to advise RemServ when this arrangement ceases. I understand that RemServ is not responsible for the return of payments made to a landlord or agent after the rental arrangement has ceased if advice of the cessation has not been provided to RemServ I understand that the rent will continue to be paid up to the end date shown below and that I will be required to confirm an extension of the rental arrangement to RemServ if I require rental payments to continue. Signature:...Date:. /.. / LANDLORD OR AGENT TO COMPLETE I...., Phone number (Landlord/Agent Name) Declare that the abovenamed is currently residing in the rental property owned/managed by myself, at the abovenamed property. at (Rental Property Address) This rental arrangement is current up to (Date) Rent amount paid $... per fortnight/month/quarter I confirm that the details for reimbursement of rent are as follows: Bank / Credit Union Name Account in Name of Bank BSB : - OR Account : I confirm that the rent is payable by cheque, made out to:... And posted to this address: Signature:...Date:... Witnessed this day of, 20 Signature of Witness (not employee) Name of Witness (please print) Application continues on the next page Page 22

23 Savings/ Investment Schemes (non superannuation) Name of Investment Company Investment company address Investment Company contact number: Policy Number Payment Amount Option 1 Regular direct payment to investment fund $ Payments to be made: [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Submit invoice with your application for RemServ to pay directly to the supplier Please attach the prospectus AND policy document/invoice which include payment information. Submit copy of supplier document showing account details if can be paid directly by electronic funds transfer (EFT). The Savings and Investment Declaration must be included if packaging this benefit. Option 2 - Regular direct debit to be reimbursed Copy of the bank statement showing the regular direct debit from the account. Please attach the prospectus AND policy document/invoice Please attach Direct Debit Reimbursement Request on page 36. The Savings and Investment Declaration must be included if packaging this benefit. Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 23

24 SAVINGS/INVESTMENT SCHEME DECLARATION I,... (Employee Name) advise that: I have chosen to package a savings/investment scheme contribution plan as part of my salary packaging. I confirm that this scheme meets the following terms: It is a managed investment fund which is structured on a unitised basis. The investment insurance product is provided by an approved life company and: i. Has a minimum term of not less than 10 years; ii. Is held under a trust pursuant to which: The policy is not able to be terminated within 10 years; And the premiums paid on the policy are not able to be accessed, borrowed against or withdrawn within 10 years except in special circumstances involving serious financial difficulties suffered by the rulee; iii. May provide for a payment in respect of death or disability; iv. Is treated as paid up if the premium payments are discontinued for any reason and will be continued so that the policy will be in force for at least 10 years before the proceeds are paid out; v. has no direct or indirect loan back arrangements attached to it. I understand that if these terms are breached except under specific circumstances such as financial hardship, that the Australian Tax Office may consider the salary packaged amounts salary and subject to income tax or fringe benefits tax. I understand that if this occurs I am liable for the tax payable. Declarant: Signed:... Name:... Date:. /.. /.. Witness: Signed:... Name:... Date:. /.. /.. Application continues on the next page Page 24

25 Self Education Expenses [ ] I will submit the invoice for payment [ ] I will submit the invoice and receipt for reimbursement. [ ] Regular reimbursement of direct debit. Please attach copy of invoice and bank statement showing direct debit payments and Direct Debit Reimbursement Request on page 36. The self education Expense Payment Declaration must be included if packaging. Total amount to package per year for Amount to package per fortnight SELF EDUCATION EXPENSE BENEFIT DECLARATION I,... (Employee Name), declare that (show nature of expense eg telephone rental): were provided to me by or on behalf of my employer during the period from.../../20.. to../../20. And the expenses were incurred by me for the following purpose(s):... I also declare that the percentage of those expenses incurred in earning my assessable income was...% I understand that this declaration is to apply to the above stated benefit and to any identical benefit* for a period of up to 5 years from the date of this declaration or until the stated percentage incurred in earning my assessable income decreases by more than 10 percent points. This declaration will also be revoked if another recurring expense payment fringe benefit declaration is provided in respect of a subsequent identical benefit. Signed:.....Date:. /.. / 20. *Note: identical benefits are ones which are the same in all respects except for any differences that are minimal or insignificant, or that relate to the value of the benefits, or that relate to change in the deductible proportion of 10 percentage or less. Page 25

26 Trauma/ Life Insurance Premiums 1. Name of Insurer Insurer s address Policy Number Payment Amount $ Option 1 - Irregular or single payments only. 1. Name of Insurer Insurer s address 2. Name of Insurer Insurer s address Policy Number Payment Amount $ 2. Name of Insurer Insurer s address Option 2 - Regular direct payment Submit invoice for payment; or Submit the invoice and receipt for reimbursement. Payment to be made: [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: Option 3 - Regular reimbursement of direct debit. Submit invoice with your application for RemServ to pay directly to the supplier. Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Please attach copy of invoice and bank statement showing direct debit payments and the Direct Debit Reimbursement Request on page 36. Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 26

27 Utilities (please submit additional copies of this page is packaging more than one payment type for different utilities) Option 1 - Irregular or single payments only. Please Attach Option 2 Regular direct payment to supplier Submit invoice for payment; or Submit the invoice and receipt for reimbursement. Name of Payee/Supplier Payment Amount Payments to be made: [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details: $ Please submit invoice with your application. Option 3 - Reimbursement of direct debit to supplier Name of Payee/Supplier Please attach copy of invoice and bank statement showing direct debits and Direct Debit Reimbursement Request on page 36. Total amount to package per year for Amount to package per fortnight Work Related Travel Expenses [ ] I will submit the invoice(s) for payment [ ] I will submit the invoice(s) and receipt(s) for reimbursement. The Expense Payment Declaration on page 37 must be included if packaging. Total amount to package per year for Amount to package per fortnight Application continues on the next page Page 27

28 Financial Adviser Form State Library of Queensland Client Details Employee Name:... Employee Payroll ID No:... I confirm that the above mentioned employee has attended the required salary packaging consultation and has received financial advice in respect of their individual salary packaging circumstances. Financial Adviser/Consultant Details Name: Contact Number:... Fax Number:... Organisation:... Postal Address:... I confirm that the above mentioned employee has : 1. Had all fees disclosed to them Yes / No 2. Received a statement identifying the effect on take home pay Yes / No 3. Had the reimbursement process explained where necessary Yes / No 4. Received a copy of all documents to be lodged Yes / No 5. Received a car comparison where applicable Yes / No The following pre tax amounts are to be packaged by the employee: $ per fortnight (including Administration Fee) to RemServ (do not include super amounts here), $ per fortnight QSuper Voluntary Contributions, and % per fortnight QSuper Standard Contributions. The employee has also chosen to package $ per fortnight under the post tax Employee Contribution Method. Please specify basis of calculations are or (are not based on 26 fortnights.) o Calculations are based on 26 fortnights in the year. o Calculations are based on fortnights. The benefit items selected by the employee are in accordance with the Arrangement and the totals do not exceed the 50% of superannuatable fortnightly salary. This document must be attached when documentation when submitted to Remuneration Services (Qld) Pty Ltd. Financial Adviser Signature: Date:.../.../20... Dealer/Financial Adviser License No or CPA or CA number :... Accredited Panel Adviser Number:..... Date:.../.../.... Application continues on the next page Page 28

29 Salary Packaging Participation Agreement State of Queensland This Agreement is BETWEEN: THE STATE OF QUEENSLAND through the State Library of Queensland (the Employer), AND (the Employee). Print Employee name The State Library of Queensland has elected to participate in SOA 250 by which the State Library of Queensland offers the Employee the option to participate in salary packaging. RemServ has been appointed by Queensland Government to administer the State Library of Queensland s salary packaging arrangements. The salary packaging will be administered by RemServ in consultation with Queensland Purchasing and DIR. The State Library of Queensland and Employee agree on the following terms and conditions: 1. The Employee may make Salary Packaging arrangements only on a prospective basis. 2. Salary Packaging will be paid fortnightly by the State Library of Queensland. 3. The employee may elect to avail of one or more of the benefit items approved by Queensland Government for salary packaging purposes, providing the aggregate gross value of the items does not exceed 50% of the projected total salary for the package year. 4. (a) The participation of the Employee in salary packaging shall be at no cost to the Employer. (b) The Employee (i) indemnifies and shall keep indemnified the Employer its servants and agents from and against all actions, proceedings, claims, demands, costs, losses, damages, liabilities and expenses which (A) may be brought against or made upon the Employer by the Employee or any other person; or (B) the Employer may incur, sustain, expend or be put to, by reason of or arising out of the participation of the Employee in salary packaging; and (ii) releases and discharges the Employer from any actions, proceedings, claims or demands which but for the provisions hereof may be brought against or made upon the Employer by the Employee by reason of or arising out of the participation of the Employee in salary packaging. 5. All taxes, charges, fees, or other costs associated with salary packaging shall be the responsibility of the Employee. Application continues on the next page Page 29

30 6. Any additional costs incurred as a result of termination or cessation of the Employee s salary package, shall be the responsibility of the Employee. The State Library of Queensland may recover such costs from the Employee as a debt due. 7. (a) If any part of the Salary Package has been paid in advance by the State Library of Queensland or RemServ and this agreement is terminated for whatever reason, the amount which has been paid which is more than the entitlement at the date of termination, shall be deducted from the Employee's termination of employment payment from the Agency in the calculation of all statutory leave entitlements by the Agency. (b) Where there is a statutory obligation on the Employee to pay entitlements to the State Library of Queensland, the Employee undertakes to pay immediately the equivalent of such amounts to the State Library of Queensland in reduction of any amount owing under this agreement. 8. In the event of the Employee's termination of employment with the State Library of Queensland for any reason whatsoever, the calculation of all statutory leave entitlements such as long service and recreation leave shall be at the rate applicable to the Employee's substantive salary. 9. On completion of the package year the balance in the fund will be rolled over to the next package year. SALARY PACKAGE COMPONENTS and REVIEW 10. (a) The components of the Salary Package may be changed as near as practical but prior to the completion of the package year which shall end on at 31 st March of each year, with the consent of the State Library of Queensland. (b) However, under any of the following defined circumstances: - separation; - divorce; - ill health; - extended leave including parental leave; - substantial change to the Employee s salary amount, Application continues on the next page Page 30

31 the Employee shall have the right to initiate a review of the components of the Salary Package prior to the completion of the package year. 11. In the event of exceptional or unintended circumstances, the State Library of Queensland may agree to prospectively vary the components of the Employee s Salary Package. A single change per year will be permitted without penalty. An additional fee of $50 may, at the discretion of RemServ, be charged for each time a change is made to the package. This fee will be payable to RemServ by the Employee. 12. (a) In the event that there are changes relating to (i) Fringe Benefits Tax (FBT) legislation; (ii) the introduction of any State equivalent to Fringe Benefits Tax legislation; or (iii) the way in which any Fringe Benefits Tax legislation is interpreted; this agreement will be renegotiated in accordance with the provisions of SOA 250. (b) Until such time as this agreement is renegotiated following changes to the FBT status of the State Library of Queensland, any FBT liability from this agreement will be the responsibility of the Employee and the Employee indemnifies Queensland Government in respect of any FBT liability borne by Queensland Government arising out of this agreement. FINANCIAL ADVICE 13. The Employee acknowledges that it is a requirement of Queensland Government that independent financial advice is sought prior to the participation in full salary packaging. ADMINISTRATION 14. The fees to be charged by RemServ for administering salary package payments made under this agreement are payable by the Employee to RemServ. The total fee amount includes government rebates. 15. The Employee must pay the fees for salary packaging in accordance with SOA 250. Application continues on the next page Page 31

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