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 firstname.lastname@example.org 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 email@example.com 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 firstname.lastname@example.org 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 email@example.com 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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