- with Bank Details -
Name of Employer «MyCompanyLegalName»
Employer ABN «MyCompanyVatRegNo»
Regarding «FirstName» «MI» «LastName»
Date of Birth «BirthDate»
1. «FirstName» «MI» «LastName» is/was employed:
«EmploymentStatus»
Other _________________________
2. On what date did Employment Commence
«StartDate»
3. «FirstName» «MI» «LastName» is/was employed for:
Hours per week: «WeeklyHours»
4 Under what name is/was the person employed?
«FirstName» «MI» «LastName»
5 What is the name of the business worked for? (if different from the one above)
Business name: ____________________________
6 Has employment ceased?
Yes What date did employment cease? «LeftDate»
No
7 If employment has not been continuous, what were the periods «FirstName» «MI» «LastName» was employed:
____ / ____ / ____ to ____ / ____ / ____
____ / ____ / ____ to ____ / ____ / ____
8 Has a worker’s compensation claim been made?
Yes
No
9 For what period was worker’s compensation paid?
10 What was the name of your insurer?
Insurer name ____________________________________
11 Please provide bank account details which you deposited salary or wages into for
«FirstName» «LastName»
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»
12 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 ______________
