Salary Sacrifice Claim Form

SALARY SACRIFICE CLAIM FORM

You should use this form to make one or more salary sacrific claims as described in the Salary Packaging Fact Sheet. If you have any questions while completing this form, please do not hesitate to call PayMe Australia on 1800 082 006 to ensure that you complete it correctly.

Note: A maximum of three items can be claimed on this form.

CLAIM DETAILS

Description of Item Claimed *

Category of Salary Sacrifice *

Total value including GST *

Work Related Component $ or % *

Is this an ongoing claim?

YesNo

Do you have a second item to claim? *

NoYes

Description of 2nd item Claimed

Category of Salary Sacrifice 2 *

Total value including GST

Work Related Component $ or %

Is this an ongoing claim?

YesNo

Do you have a third item to claim? *

NoYes

Description of third item claimed

Category of Salary Sacrifice 3 *

Total value including GST

Work Related Component $ or %

Is this an ongoing claim?

YesNo

DEDUCTION REQUEST

Note: this option is subject to PayMe approval.

Please make the deduction: *

in full in one pay cycleover a number of pay cycles.

$ Amount per pay *

Number of pay cycles *

Attach Receipts *

Browse

A copy of the original tax invoice / proof of purchase (where the product, amount and GST are clearly identifiable) must be attached before this claim can be considered.

CERTIFICATION

I declare that the above expense(s) is directly related to my work, I understand and acknowledge that:

I am wholly responsible for this salary sacrifice claim.
I am responsible for obtaining independent financial advice regarding the salary sacrifice of this item. PayMe accepts no liability should I fail to seek financial advice or for any financial advice I have independently sought.
PayMe accepts no liability should I incur additional income tax or other costs, now or in the future, as a result of this salary sacrifice claim.
I agree to reimburse PayMe the full cost of any Fringe Benefits Tax liability or penalty incurred as a result of this salary sacrifice claim.
If my contract terminates before the full amount is able to be salary sacrificed, any outstanding amount will be settled in my final pay.

Please note: This expense(s) should not be claimed again in your personal income tax return, as the ATO would consider it to be double-dipping.

Full Name *

Email *

Phone: *

Date *

Signature *

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