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Declaration

Payroll Tax: Nomination of Designated Group Employer

Fields marked with * are required

Collection statement

The SRO provides this form to enable the Group Employer to nominate a Designated Entity to claim the payroll tax threshold. If you do not provide the information requested, the SRO is unable to allocate the payroll tax threshold deduction. The information collected may be used for the purposes of other SRO legislation. Where authorised by law to do so, we may 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 information in the 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

Signature

Date (DD/MM/YYYY)

First name

Middle name(s)

Family name

Position (if applicable)

Organisation (if applicable)

Mobile number

Phone number

Email

Nominated member

Payroll Tax: Nomination of Designated Group Employer

Fields marked with * are required

Nominated member

Legal name

Name of company

ABN

ACN

SRO customer number

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

Mobile number

Phone number

Email

Date of joining group (DD/MM/YYYY)

This nomination is effective from (DD/MM/YYYY)

Other members

Payroll Tax: Nomination of Designated Group Employer

Fields marked with * are required

Other members

Other member

Please provide details for other members who pay wages in or outside Victoria or members who do not pay wages but are located in Australia (not including the nominated member)

Victorian member

Non-Victorian member

Legal name

Name of company

ABN

ACN

SRO customer number

Date of joining group (DD/MM/YYYY)

If there is insufficient space please attach a document schedule and additional supporting documents in Submission Attachments.

Summary

Payroll Tax: Nomination of Designated Group Employer

Fields marked with * are required

Nominated member

Legal name

Name of company

ABN

ACN

SRO customer number

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

Mobile number

Phone number

Email

Date of joining group (DD/MM/YYYY)

This nomination is effective from (DD/MM/YYYY)

Other members

Other member

Please provide details for other members who pay wages in or outside Victoria or members who do not pay wages but are located in Australia (not including the nominated member)

Victorian member

Non-Victorian member

Legal name

Name of company

ABN

ACN

SRO customer number

Date of joining group (DD/MM/YYYY)

If there is insufficient space please attach a document schedule and additional supporting documents in Submission Attachments.