In House Reimbursement Claim Declaration Form with stat dec by MikeCallan

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									Queensland Government In-house Bene ts
Reimbursement Claim & Declaration Form                                                                                         GPO BOX 424
                                                                                                                         BRISBANE, QLD 4001
Queensland Government In-house bene ts include electricity and public transport. To make a reimbursement                            Australia
claim for either of these bene ts to a combined maximum of $1,333.33 per Fringe Bene ts Tax (FBT) year you             Government Enquiries:
are required to complete and submit to RemServ the following form with both sides of your electricity bill or copies           1300 30 40 10
of your transport receipts displaying proof of purchase. Before completing this form please read the below
                                                                                                                           Fax: 1300 30 18 66
important information.                                                                                                   www.remserv.com.au

PLEASE READ THE BELOW BEFORE COMPLETING YOUR CLAIM
IMPORTANT INFORMATION ABOUT MAKING AN IN-HOUSE CLAIM
Checklist for Submitting your Claim
1. Please submit both pages of this form including this page
2. Copies (not originals) of invoices and/or receipts must accompany this request for payment to be processed
3. For electricity claims - Both sides of the bill need to be submitted along with proof of payment
4. For public transport claims - Please ensure that you forward your GoCard history statement or photocopies of your transport tickets
   showing the actual dollar value, on A4 size copy paper with your request
5. For public transport claims - You MUST complete and sign the employee declaration to receive reimbursement
6. You can submit your claim either via:

        a) Fax - 1300 30 18 66
        b) Email - remserv@remserv.com.au with scanned documents attached
        c) Post - RemServ, GPO Box 424, Brisbane QLD 4001

Employee Declaration
You MUST complete and sign the employee declaration on the following form for your claim to be processed.

Things to Note when Making a Claim
1. Where there are insu cient funds to meet the request Remuneration Services (Qld) Pty Ltd (RemServ) will make partial payments
   unless otherwise advised
2. When the total bene t payment is reached ($1,333.33), RemSev will only pay up to this amount in the current FBT year. Any
   amount not paid in full for the current FBT year will be set-up to be paid to you in the new FBT year , once funds have accumulated
3. Employees from the concessionally taxed employment areas who are already packaging utilities will have any payments beyond
   $1,333.33 limit paid from within the cap limit
4. Four claims per FBT year are included (electricity and/or public transport) in your in-house bene t fee. Further claims are
   processed at an additional charge of $25.00 per claim
Client Survey
As part of our contract with your employer for the provision of salary packaging services, Remuneration Services (Qld) Pty Ltd (RemServ)
engages a third party to conduct client surveys on its behalf. Below you have the option to provide consent or indicate that you
do not consent to be contacted by a third party engaged by RemServ to participate in client surveys.

PLEASE COMPLETE & SUBMIT WITH FORM

Client Survey Consent

 I                                                                                  (Full Name)


     consent to be contacted by a third party engaged by RemServ to participate in client surveys
     do not consent to be contacted by a third party engaged by RemServ to participate in client surveys


Privacy Notice
Remuneration Services (Qld) Pty Ltd (RemServ) is collecting your personal information on this form for the purpose of processing your
salary packaging arrangements. RemServ will pass your personal information on to your payroll section as part of the administration of
your salary packaging arrangements. RemServ may give your personal information to other persons, bodies or agencies without your
consent, in circumstances where legislation requires or authorises disclosure.
Queensland Government In-house Reimbursement Claim & Declaration

My Employer is:                                                                              RemServ ID:
                                                                                                                                                                  GPO BOX 424
                                                                                                                                                            BRISBANE, QLD 4001
First Name:                                                                 Last Name:                                                                                 Australia

                                                                                                                                                        Government Enquiries:
Address:                                                                                  State:                 Post Code:                                     1300 30 40 10

                                                                                                                                                             Fax: 1300 30 18 66
Contact Email:                                                                            Contact Phone:                                                   www.remserv.com.au


       PLEASE ENTER THE DETAILS OF THE ITEMS YOU ARE CLAIMING IN THE FIELDS BELOW

            Receipt Date                                             Payment For                                                  GST               Total Amount




                                                                                                                                 TOTAL
   Payments will be made by electronic funds transfer (EFT) to your nominated account
           Use account details held on le                           Use account details below (Please ensure to provide your BSB & Account number below)

    BSB                                                        Account Number

   EMPLOYEE DECLARATION - You MUST complete this section for all claims

   I                                                                                                                              (Employee Name) declare that:

   (a) I am claiming a reimbursement for the costs of electricity services provided by a Queensland Government generator and/or public transport services supplied by
       Queensland Rail and/or Brisbane City Council buses and ferries only.
   (b) The attached invoice/s, receipt/s or GoCard history statements are for expenses incurred privately by myself or by a family associate and are budgeted for within
       my salary packaging.
   (c) If I am claiming reimbursement for electricity:
      (i) The attached electricity invoice/s are in the name of:
                the claimant              Spouse
                                          spouse               Defacto Partner (living with the claimant)           Relative living with the claimant

        (ii) I declare that the attached invoice/s are for:
                 My current primary place of residence        OR         A previous primary place of residence

   (d) If I am using a GoCard then:
      (i) I have used, and will continue to use, the GoCard for the costs of public transport services supplied by Queensland Rail and/or Brisbane City Council buses and
           ferries only;
      (ii) I have not made any redraws of credit from the GoCard for the period to which the claim for reimbursement relates; OR

           I have redrawn the amount of                            from the GoCard for the period to which the claim for reimbursement relates and my claim for
            reimbursement does not include the amount that I have redrawn;
        (iii) On request by the Employer, I will provide to the Employer and/or RemServ all records, receipts, documents accounts and supporting information reasonably
              required by the Employer to enable the Employer to determine whether the GoCard has been used solely for Queensland Rail and/or Brisbane City Council
              bus and ferry travel; and
         (iv) I declare that the address given above was my usual place of residence during the period of this reimbursement for public transport and that my
               usual place of employment during this period was

                                                                                                   (State the place where you usually work)

   I acknowledge that I am liable for all costs, losses, outgoings and liabilities, including, without limitation, any penalties, or general interest charge payable under any
   taxation legislation su ered or incurred by the Employer, arising out of my failure to comply with the preceeding paragraph, in accordance with the terms and
   conditions of my salary packaging participation agreement.

 Privacy Notice
 Remuneration Services (Qld) Pty Ltd (RemServ) is collecting your personal information on this form for the purpose of processing your salary packaging arrangements.
 RemServ will pass your personal information on to your payroll section as part of the administration of your salary packaging arrangements. RemServ may give your
 personal information to other persons, bodies or agencies without your consent, in circumstances where legislation requires or authorises disclosure.

       Signature:                                                                                                              Date:


                    FAX to 1300 30 18 66, email to remserv@remserv.com.au or send to GPO Box 424, Brisbane QLD 4001

								
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