Living Away from Home Allowance Declaration Form

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              Living Away from Home
              Allowance Declaration Form
                   Please supply all details below for Australian Bank Accounts Only and return to:

                   The Billing and Remuneration Department
                   Entity Solutions Pty Ltd
                   Level 11, 410 Collins Street
                   Melbourne VIC 3000
                   National Payroll Fax number: 1800 306 266
                   Phone number: (03) 9600 - 0333



                   DECLARATION 11



                   TAX PAYER’S NAME

                   TAX FILE NUMBER

                   YEAR ENDED

                   EMPLOYER



              I,                                                  , declare that during the period of                            to
              , was required to live away from my usual place of residence in order to perform the duties of my employment. During that period my
              usual place of residence was: (State place where you usually live)
                                                                                                        and the nature of the residence was private.


              During the period the place at which I actually resided was:
              (State all addresses at which you resided while away from home in the period stated above)




              I declare that the cost of temporary accommodation is $              per Week.
              Please specify (✓) if with a dependant spouse ❒ and/or number of dependant children                (under 12)                   (over 12 years).


                   SIGNATURE


                                                                                                                        DATE             /           /

                                          NB: Dependant: People who need your financial support and whom you look after.



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Description: Living Away from Home Allowance Declaration Form