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Declaration

Payroll Tax: Employment Agency Contracts – Declaration by Exempt Client

Fields marked with * are required

Collection statement

The SRO provides this form to assist employment agents to determine whether wages paid to a service provider are exempt. If you do not provide the information requested, the employment agent may be required to pay payroll tax on wages which would otherwise be exempt. In most cases this form will be retained by the employment agent, and they can inform you how they will manage your personal information. If this information is later provided to the SRO, the information may be used for the purposes of other SRO legislation. Where authorised by law to do so, the SRO 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 the SRO uses 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.

I declare that the wages paid to the service provider would have been exempt from payroll tax under Part 4 (other than Division 4 or 5 of that Part, Section 50 or clause 16 of Schedule 2) of the Payroll Tax Act 2007 if the service provider had been paid directly by the client as an employee.

Signature

Date (DD/MM/YYYY)

First name

Middle name(s)

Family name

Position (if applicable)

Organisation (if applicable)

Mobile number

Phone number

Email

Declarant details

Payroll Tax: Employment Agency Contracts – Declaration by Exempt Client

Fields marked with * are required

Declarant details

Client name

Name of company

ABN

ACN

Client 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

Employment agent details

Payroll Tax: Employment Agency Contracts – Declaration by Exempt Client

Fields marked with * are required

Employment agent details

Employment agent name

Date of contract with client (DD/MM/YYYY)

This consent is voluntary and is only to be used to verify your payroll tax exempt status.

I agree to allow the SRO to provide the employment agent with information about our payroll tax exempt status for confirmation purposes.

Summary

Payroll Tax: Employment Agency Contracts – Declaration by Exempt Client

Fields marked with * are required

Declarant details

Client name

Name of company

ABN

ACN

Client 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

Employment agent details

Employment agent name

Date of contract with client (DD/MM/YYYY)

This consent is voluntary and is only to be used to verify your payroll tax exempt status.

I agree to allow the SRO to provide the employment agent with information about our payroll tax exempt status for confirmation purposes.