Sample Claim Form Queensland by wzt64827

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									                                                                                                      LONG SERVICE LEAVE
                                                                          claim form GUIDE
          IMPORTANT
          Please ensure that:                                                                The claim form will be returned if:
          > your long service leave claim form and copies of all                             > copies of all proof documentation are
            documentary evidence are received by QLeave more than                              not attached. Please do not supply
            10 working days before your nominated payment date                                 originals as QLeave cannot guarantee
          > the address on the claim form is current, as this is                               these will be returned.
            where your Payment Summary will be sent.


THIS IS TO BE USED AS A GUIDE ONLY
PLEASE COMPLETE THE CLAIM FORM SEPARATELY
Section 1 – Claim Details

  1. CLAIM DETAILS Please only tick ONE claim type
      ✓10 year long service 1                                                          0 1 / 0 1
                                               What is the first day of this claim period?                    /    2 0 1 0
                                       2       How many days entitlement are you claiming? 1 0




                                                                                                LY
                                                                                                         s
                                               Will a regional show day fall in your work area during this time?
                                           3



                                                                                             ON
                                                         No    Yes Name of work region

                                           4                             u
                                               Is your Employer paying you during this leave?      No       Yes




OR
         6
        Permanently leaving
        the industry
                                           5     en
                                               When do you want the payment made?




                                               7
                                                     R
                                                    OR

                                               Reason f leaving the industry:
                                                      for
                                                         As soon as possible
                                                                               E                     p
                                                                                 (Refer to guide for processing times)
                                                           ✓Delay payment until 0 1 / 0 1 / 2 0 1 0
                                                                                     Bona fide redundancy            Invalidity

                         cancel your
        (This claim will can                       Approved early retirement         Other
                 registration)
        QLeave registra

OR      Personal representative                This must be completed by an authorised representative of the deceased worker
         8                                     Your name

                                               Address

                                                                                                    Phone




You must select one claim type only.
10 YEAR LONG SERVICE
    1 Your long service leave cannot begin on a weekend or public holiday. You will receive payment for a public
      holiday/s if it falls within your leave period. You must be on long service leave (paid by QLeave) on the working
      days immediately before and after the public holiday to receive the additional payment.
    2 You must claim a minimum of 5 working days leave.




For further assistance please call 1800 803 491 or email claims@qleave.qld.gov.au                                                  PAGE 1
     3 If there is a Regional Show day in your work area within the claim period, please specify the date and your work
       region.
     4 Refer to Section 5 - Tax Details
     5 If you are taking a period of leave that spans a financial year and you want full payment before the leave commences,
       the full amount will appear on your payment summary for the year in which it is paid.
     > If you are taking a period of leave that spans a financial year and you want to split the payment over the two
       financial years, please submit two claims:
          ≥ One for the period up to 30 June; and
          ≥ One for the period commencing 1 July. (Claim for this period commencing 1 July cannot be paid before that
            date i.e. payment will be made in the new financial year.)
          ≥ In this instance you will receive two separate payment summaries.

PERMANENTLY LEAVING THE INDUSTRY
   6 You must be permanently leaving the building and construction industry to be eligible to make this claim.
   > Your QLeave worker membership will be cancelled after the claim has been processed.
   7 Reasons for ceasing employment:

     Bona fide redundancy – the Australian Taxation Office has described this as:
        ≥ the employee must have been dismissed from a job, not having left voluntarily;
        ≥ the employee must have been made redundant (where the employee’s particular work has ceased or tapered
            off or the workplace has been relocated); and
        ≥ the dismissal must have been made before the employee has to retire (for example, before age 65, or before
            a set period of service).
     Invalidity – when physical or mental incapacity stops an employee from continuing in their present line of work,
     forcing them to leave employment early (and in any event before age 65). Invalidity needs to be certified by two
     qualified medical practitioners.
     Approved early retirement scheme – a scheme devised by an employer offering incentives to encourage staff to
     retire early or resign. The details of the scheme must be submitted to and approved by the Australian Taxation Office
     before any concessional tax rates apply.
     Ensure that you provide proof if the reason for terminating your employment
     is due to bona fide redundancy, invalidity or approved early retirement.

8   PERSONAL REPRESENTATIVE
    > Please ensure that you attach a copy of a death certificate
    > Ensure that you are able to provide evidence, such as
          ≥ in the case of an executor, proof of authority to act as the executor
          ≥ in the case of a spouse, a copy of the marriage certificate or other evidence such as a joint bank account
          ≥ in the case of a defacto partner, evidence of the relationship such as a joint bank account, joint ownership of
            property or other supporting information.


Section 2 – Interstate Schemes


    2. INTERSTATE SCHEMES                   Additional processing time may apply to these claims




                               LE O
                                                                                                         ✓


                          SAMP
                                  ther
         Are you a member of any other building and construction industry long service leave scheme/s
                                                                                             scheme/s?    Yes   No
         If yes, complete membership numbers: NSW      W3344667                   C
                                                                                VIC                       ACT

                     SA                           WA                            TAS                        NT




> Your claim will be processed against your Queensland entitlement prior to using any interstate service.
> If interstate service is accessed, the interstate component of your claim is calculated in accordance
  with the policies of those schemes.
> Additional processing time may be required if your claim includes interstate service.
> Queries concerning the calculation of other schemes’ payments should be directed to the particular
  state or territory scheme. Contact details are available at www.qleave.qld.gov.au.




For further assistance please call 1800 803 491 or email claims@qleave.qld.gov.au                                     PAGE 2
Section 3 – Proof of rate of pay

  3. PROOF OF RATE OF PAY                          PLEASE ATTACH PROOF OF MOST RECENT RATE OF PAY
                                                   TO THIS FORM OR YOUR CLAIM WILL BE RETURNED.


> Your proof of rate of pay may be copies of one of the following:
          ≥ for employees your most recent payslip stating ordinary working hours, hourly rate, allowances (if any)
          ≥ for employees a letter from the employer stating your standard working hours, hourly rate, allowances
            specified separately, type of work performed
          ≥ for labour only subcontractors a tax invoice with hours worked and hourly rate of pay
          ≥ for working directors a letter from the accountant stating your standard working hours, hourly rate, allow-
            ances specified separately, type of work performed (where claimant is a working director)
> For workers who are employed under an Award or Certified Agreement, the component of your claim that relates to
  Queensland service is calculated using the weekly rate of pay for ordinary hours worked (usually 36 or 38) as stipulated
  in the applicable Award of Certified Agreement. Overtime is NOT included in the calculation.
> For workers NOT employed under an Award or Certified Agreement, the component of your long service leave claim
  that relates to Queensland service is calculated on the basis of a 38 hour week at your normal hourly rate.
> A maximum wage rate applies. Details of the current maximum rate are available on QLeave’s website.
  Failure to attach copies of proof of pay rates will result in your claim being returned.


Section 4

  4. CURRENT/LAST EMPLOYER FOR WORK PERFORMED IN QUEENSLAND



                                                      ONLY
     Employer name     QLEAVE CONSTRUCTIONS P/L


                                                  PLE
      ✓I am currently employed by the above employer
                       mployed     he       em                     yer      com
                                                        (Your employer must complete Section 7B)
                                                                                                               m
                                                                                                   (Employer must comp compl
                                                                                                                       complete Section 7B
     OR              te
                      e
              last date worked for above employer was           /          /                       if this date is in the last 4 weeks)

                    ease
                     ase
     Worker type (please tick one type)     Labour on subcontractor
                                              bour only su                      ✓Employee (PAYG)                  Working Director

     What type of work is/was performed?    CARPENTER


For workers who are currently employed, please ensure that Section 7B is completed by your Employer.


Section 5
> Your long service leave payment will be
  taxed as follows:                                     5. TAX DETAILS (not required for personal representative claims)                      6. BANK AC



                                                                     ONLY
     ≥ If you have not supplied a tax file
       number, tax will be deducted at the                  Tax file number 1 1 1 2 2 2 3 3 3                                                     A unt
                                                                                                                                                 Account na




                                                                MPLE
       top tax rate plus the medicare levy.                       Do you want to claim the tax-free threshold for                                BSB



                                                             SA
     ≥ If you are not going to be paid by                         this payment?
       your employer during your long
       service leave, tax will be deducted
                                                                    ✓Yes       N (Y
                                                                               No (You can claim the tax-free threshold
                                                                                                                                                 Account No

                                                                                   from only one payer at a time.)
       in accordance with the Pay as You
       Go Withholding Tax Tables supplied
       by the Australian Taxation Office
       taking into account the information supplied.
     ≥ If you are going to be paid by your employer during your long service leave, tax will be deducted from the
       QLeave payment at your marginal tax rate, which may vary between 31.5% and 46.5% depending on your
       weekly wage and whether you have claimed the tax free threshold.
     ≥ For more information on the tax free threshold and what it means to you, please contact the
       Australian Taxation Office.




For further assistance please call 1800 803 491 or email claims@qleave.qld.gov.au                                                            PAGE 3
Section 6
> EFT is the method of payment                                            6. BANK ACCOUNT PAYMENT DETAILS
> Please contact QLeave should you                                            Account name        JOE CITIZEN


                                                                        PLE O
  require other arrangements.
                                                                                     0 6 4 1 1 1


                                                                     SAM
                                                                              BSB
                                                                               SB

                                                                               ccount
                                                                              Account No.    3 4 5 6 7 8 9




Section 7

 7. CERTIFICATION Penalties may apply for providing false or misleading information
 1 (A) Worker
      I certify that     ✓all information provided is true and correct
                         ✓I have not been paid for part/all of this long service leave claim by the employer
                         ✓I have attached all proof/documentation required for this claim
      Signature        Joe Citizen                                            Date   2 0/1 2          /   2 0 0 9
 2    (B) Employer
      I certify that   ✓the Employer has not paid for part/all of this long service leave claim
      Gross ordinary weekly rate of pay $ 1000–                                 week OR ✓38 hour week




                             MPLE
                                                               r
                                                             for a      36 hour w

                         QLEAVE CONSTRUCTIONS                                                             5000

                           SA
      Employer name                                                                  Em oyer
                                                                                     Employer number R

      Contact name       SAM SMITH                                                   Contact title   PAYROLL MANAGER
      Signature        Sam Smith                                              Date   2 0/1 2          /   2 0 0 9
 3    (C) Personal representative (only required for personal representative claims)
      I certify that       all information provided is true and correct
                           I have attached a death certificate and all proof/documentation required for this claim
                           I am authorised to act on behalf of the deceased worker
                           this worker has not been paid for part/all of this long service leave claim by the employer

      Signature                                                               Date            /       /




1    Section 7A must be completed by workers who are submitting a 10 year long service leave or permanently leaving
     the industry claim.
2    Section 7B must be completed by the Employer for workers submitting a claim for: (a) 10 years long service and
     the worker is currently employed by that employer (b) permanently leaving the industry - where the worker has
     ceased work within the last 4 weeks.
3    Section 7C must be completed by the personal representative of the deceased worker.

    Providing false and/or misleading information may incur penalties.



                                Level 4, Centro Lutwyche, 543 Lutwyche Rd, Lutwyche Q 4030 | PO Box 512, Lutwyche Q 4030
                                Phone 07 3212 6811 | Fax 07 3212 6844 | Web www.qleave.qld.gov.au
                                Helpline
                                Free Call 1800 803 491 | Email claims@qleave.qld.gov.au



This publication is produced and distributed as a general information source. QLeave does not                            PAGE 4
accept liability to any person for the information or advice provided or incorporated by reference.

								
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