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Friday, 10 May 2024

Employment Declaration (1)


                                    Centrelink Employment Declaration 
                                                - with Bank Details - 


 Name of Employer «MyCompanyLegalName» 
 Employer ABN «MyCompanyVatRegNo» 
 Regarding «FirstName» «MI» «LastName» 
 Date of Birth «BirthDate» 

 Employment Status «EmploymentStatus»

 Date of Commencement «StartDate»

 Hours Worked Per Week «WeeklyHours»

 Employed Under Name «FirstName» «MI» «LastName» 

 Name of Business worked for (if different from above)

 Date Employment Ceased (if applicable) «LeftDate» 

 Dates of employment (where employment has not been continuous)
 ____ / ___ / ___ to ___ / ___ / ___ 
 ___ / ___ / ___ to ___ / ___ / ___ 
 ___ / ___ / ___ to ___ / ___ / ___ 

 Workers’ Compensation Claim 
(answer Yes or No)

 Period of time Workers’ Compensation Paid For

 Name of Workers’ Compensation Insurance Company

 Net Pay paid into: 
Bank Name «BankName»
Branch Code «BankCode» 
Account Name «BankAccountName» 
Account Number «BankAccountNumber» 

Deduction paid into:
Bank Name «Bank2Name» 
Branch Code «Bank2Code» 
Account Name «Bank2AccountName» 
Account Number «Bank2AccountNumber» 

Deduction paid into: 
Bank Name «Bank3Name» 
Branch Code «Bank3Code» 
Account Name «Bank3AccountName» 
Account Number «Bank3AccountNumber» 

Refer to the attached Statement of Payments showing the date and amount of each wage payment to the person named above for the required period. 

«Signature» 
«Title» 
«MyCompanyPhoneNumber» 
«LetterDate» 

 If this form was completed by a business with fewer than 20 employees, please provide estimate of the time taken to complete it. Please include the actual time spent for each employee involved, in reading the instructions, obtaining the information and providing the answers. 

 Hours __________ Minutes ______________


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