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Declaration

General form 01: Application for refund

Fields marked with * are required

Privacy statement

This information is collected by the SRO to determine whether you are entitled to a tax refund. If you do not provide the information required, we may not be able to process your application for a refund of tax. The information collected may be used for the purposes of other SRO legislation. Where authorised by law to do so, we may also disclose this information to other government agencies including the ATO, State and Territory revenue offices, and law enforcement agencies. You can find out more about how we use and protect your information in our Privacy Policy on www.sro.vic.gov.au.

Declaration

I declare that I am authorised to make this declaration.

The information provided on this form and in any attached documents is complete and correct. I understand that penalties apply for giving false or misleading information or omitting information.

The Electronic Transactions (Victoria) Act 2000 establishes the regulatory framework for transactions to be completed electronically. This form requires you to complete an electronic signature via tick-box before lodgment. By ticking the box you indicate your approval of the contents of this electronic communication.

Date

XMLDate

Signature

Date (DD/MM/YYYY)

Title

Other

XMLSalutation

First name

Middle name(s)

Family name

XMLGivenNames

XMLSignature

Position (if applicable)

Mobile number

Phone number

Email

XMLContactNumber

The State Revenue Office can contact me at this email address and phone number.

Customer details

General form 01: Application for refund

Fields marked with * are required

Customer details

Is the customer an individual or an entity?

Individual

Entity

Individual

First name

Middle name(s)

Family name

Date of birth (DD/MM/YYYY)

Entity

Name of entity

ABN

ACN

Contact name

First name

Middle name(s)

Family name

SRO customer number

Mobile number

Phone number

Email

Authorised representative

Are you an authorised representative?

Yes

No

Representative's postal address

Country

Australian address

What is the type of address?

Street

PO Box

Lot number

Floor/Level type

Floor number

Flat/Unit type

Unit number

PO Box number

Post office name

Lot number

Street number

Street name

Street type

Suburb/Town

State

Postcode

International address

Street address/Postal address

Suburb/Town

State

Postcode/Zipcode

Overseas Address

Please provide an authority from the taxpayer. If this form is lodged without an authority from the taxpayer, the refund application can not be processed.

Refund details

General form 01: Application for refund

Fields marked with * are required

Refund details

Specify the tax type(s) (e.g. land tax, payroll tax, duties, etc.) the refund relates to:

Amount of the refund claimed:

Date of payment (DD/MM/YYYY)

Or

Payment period:

From date (DD/MM/YYYY)

To date (DD/MM/YYYY)

Provide the reason for this refund request:

Has the tax or duty subject to refund claim been charged or recovered from another person or organisation (see TAA.002- ‘Windfall Gains’, available from the SRO website)?

Yes

No

Provide details

Payment details

General form 01: Application for refund

Fields marked with * are required

Payment details

Refund will be paid by electronic funds transfer (EFT) into a single nominated bank account. Provide EFT details for payment.

Financial institution

Account name

BSB number

Account number

Supporting documents

General form 01: Application for refund

Fields marked with * are required

Document checklist

To support your application, you should upload relevant information and documentation.

Authority from the taxpayer allowing you to act on their behalf.

Previous correspondence received from the SRO (e.g. Investigation letter outcome).

Supporting documents

Supporting document

File:

Summary

General form 01: Application for refund

Fields marked with * are required

Customer details

Is the customer an individual or an entity?

Individual

Entity

Individual

First name

Middle name(s)

Family name

Date of birth (DD/MM/YYYY)

Entity

Name of entity

ABN

ACN

Contact name

First name

Middle name(s)

Family name

SRO customer number

Mobile number

Phone number

Email

Authorised representative

Are you an authorised representative?

Yes

No

Representative's postal address

Country

Australian address

What is the type of address?

Street

PO Box

Lot number

Floor/Level type

Floor number

Flat/Unit type

Unit number

PO Box number

Post office name

Lot number

Street number

Street name

Street type

Suburb/Town

State

Postcode

International address

Street address/Postal address

Suburb/Town

State

Postcode/Zipcode

Overseas Address

Please provide an authority from the taxpayer. If this form is lodged without an authority from the taxpayer, the refund application can not be processed.

Refund details

Specify the tax type(s) (e.g. land tax, payroll tax, duties, etc.) the refund relates to:

Amount of the refund claimed:

Date of payment (DD/MM/YYYY)

Or

Payment period:

From date (DD/MM/YYYY)

To date (DD/MM/YYYY)

Provide the reason for this refund request:

Has the tax or duty subject to refund claim been charged or recovered from another person or organisation (see TAA.002- ‘Windfall Gains’, available from the SRO website)?

Yes

No

Provide details

Payment details

Refund will be paid by electronic funds transfer (EFT) into a single nominated bank account. Provide EFT details for payment.

Financial institution

Account name

BSB number

Account number