Salary Packaging Application Forms

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ãRemuneration Services (Qld) Pty Ltd

This work is copyright. It may be reproduced in whole or in part for Queensland Government purposes subject to the inclusion of any acknowledgement of the source and no commercial usage or sale. Reproduction for the purposes other than those indicated above, requires the prior written permission from Remuneration Services (Qld) Pty Ltd. Requests and enquiries concerning reproduction and rights should be addressed to Remuneration Services (Qld) Pty Ltd, GPO Box 424, Brisbane QLD 4001.

Privacy Policy : RemServ is committed to adhering to National Privacy Principles (NPP) 1-10 as defined by the Office of the Federal Privacy Commissioner in accordance with the Privacy Act 1988.

Version 3.10 Remuneration Services (Qld) Pty Ltd

Call centre 1300 30 40 10 Page 1

Salary Packaging Application Forms

The following forms for salary packaging of superannuation and/or other benefits follow. If packaging

superannuation only, you should use the forms from the Superannuation Salary Packaging Booklet.

1. Salary Packaging Application This is the main document, which must be completed for packaging to commence.

2. Financial Adviser Form This must be included with your application when packaging benefits other than superannuation only. Your adviser must sign this document and include his/her registration or adviser number.

3. Salary Packaging Participation

Agreement This document must be included with your application. RemServ canarrange for the employer signature, but you must ensure that you sign and date this document before sending.

Additional Documents

4. Direct Debit Reimbursement Request For benefits that you pay by direct debit where reimbursements are required. One form for each benefit paid in this way should be included with your application as applicable.

5. Expense Payment Benefit

Declaration Include this declaration if packaging:· Airport Lounge Membership

· Briefcases, calculators, tools of trade, and protective clothing · Home Office Expenses

· Mobile Phone Expenses

· Professional Memberships and Subscriptions · Work Related Travel

6. BP Fuel Card Confirmation of Details This form is for use where vehicle details are not available at the time of application.

7. Landlord Declarations Include one of these declarations if packaging home rental expenses where other forms of substantiation are not available. Your landlord will need to complete a portion of the declaration.

8. Third Party Authorisation Use this form to authorise your partner, associate or financial adviser to act on your behalf.

9. Payments/Reimbursement Claim Form

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State Library of Queensland

Remuneration Services (Qld) Pty Ltd GPO Box 424 Brisbane QLD 4001 Salary Packaging Application Form Enquiries: 1300 30 40 10

Confidential Contact Details

Title____Given Names___________________________Surname_________________________________ Preferred Name (if different)________________________ Date of Birth _____/_____/______ Gender: M / F Telephone: Work ( ) ______________________ Home ( ) _________________________________ Work Fax ( ) _________________________ Home Fax ( )_________________________________ Mobile __________________________________

Home Address: ______________________________________________________________________ Suburb ____________________________________________ Post Code _________________ Home Postal Address (if different from above):________________________________________________ Suburb ____________________________________________ Post Code ________________ Name of Employer:______________________________________________________________________ Work Address :_________________________________________________________________________ Suburb _________________________________________ Post Code ____________________ Position Title: __________________________________________________

Work E-Mail __________________________________________________

Personal E-Mail _________________________________________________________ Address for forwarding of correspondence/statements: Home [ ] Business [ ] Payroll Details

Payroll ID Number _________________ Payroll Office (where applicable) _____________________________

Corporate Office/Statewide Service/District (where

applicable)___________________________________________

Pay Status (circle one) Permanent: Full Time / Part Time Contract/Temporary: Full Time / Part Time Statements to be sent: Monthly [ ] Quarterly [ ] Annually [ ] via Internet only [ ]

Please contact (tick one) [ ] Me [ ] My financial adviser if any clarification is required for my application.

Please include a Third Party Authorisation form if you wish your adviser to act on your behalf on an ongoing basis. Acceptance

I hereby authorise the payroll officer to make the amendments or commencements to my pre and or post tax salary, as indicated, with effect from the next available pay fortnight, until further notice. I confirm that the total of all benefits packaged (including superannuation) is 50% or less of my fortnightly superannuable salary. I

understand the figures that I have represented here will be processed by RemServ and submitted to my pay office. Name (printed) ... Pay roll office : ...

Signature ... Date ... ..

Office use Only

Standard percentage Defined [ ] Accumulation [ ] State [ ] %

Additional voluntary $

Pre tax $

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 3 Superannuation

If packaging superannuation as the only benefit, please refer to the Superannuation Salary Packaging Booklet and submit the QSuper salary packaging forms from that booklet.

· If you wish to package your standard superannuation contribution go to Part A.

· If you wish to package additional voluntary superannuation contributions to Part B.

*If you are unsure which QSuper account you have, or have any other queries contact Qsuper on 1300 360 750.

Part A. Standard Contributions to Superannuation Defined Benefit Account

Please tick only ONE box for the standard percentage (either non gross up or gross up, NOT both)

Reduced Rates Standard Rate Catch up Rates Only

2% 3% 4% 5% 6% 7% 8%

Non Gross Up %

2.35% 3.52% 4.70% 5.88% 7.05% 8.23% 9.41%

Gross Up %

Catch up rates are only available for pre-approved Defined Benefit members catching up contributions after previously paying at a rate less than 5%.

Selecting the gross up contribution amounts will ensure you receive the greatest end benefit, as you will have covered the 15% contributions tax.

Accumulation Account

Please tick only ONE box for the standard percentage

Reduced Rates Standard Rate

2% 3% 4% 5%

Non Gross Up %

State or Police Account (please delete which does not apply) My contribution per fortnight should be:

IMPORTANT: You must contact QSuper to obtain the correct contribution information for this

section, as contribution rates differ on an individual basis. Rate must reflect that which is advised in writing by QSuper.

%

Part B Voluntary Contributions

If you do not wish to make additional voluntary contributions, please leave this box blank and complete the rest of the application on the following page.

I wish to make additional voluntary contributions from pre tax dollars.

My voluntary contribution per fortnight should be: $

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TOTALS

Please total all benefits packaged on the following pages, including the administration fee

Total Amount per fortnight per year

Total Amount from Pages 5 - 18 $ $

FBT provision amount (where applicable) TOTAL AMOUNT PACKAGED

(This amount should exclude amounts for superannuation) $ $

I require post tax deductions to be contributed (ECM). The amount per fortnight is:

Please note that post tax contributions should not be less than $20.00 per fortnight. $

Please complete this section if it applies to you. It is your responsibility to ensure that any additional fringe benefits are reviewed as part of your salary packaging as there are fringe benefit tax

implications.

I have non salary packaged fringe benefits (eg car or mobile phone provided by the employer). The Grossed Up Taxable Value (GUTV) per year (estimate) is: $

Bank Account for Reimbursements if applicable

Bank / Credit Union Name ___________________________________________________________ Account in Name of ___________________________________________

Bank BSB : ___|___|___ - ___|___|___ Account : ___|___|___|___|___|___|___|___|___

Please specify basis of calculations (are or are not based on 26 fortnights.)

o

Calculations are based on 26 fortnights in the year.

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 5

ADMINISTRATION FEE PACKAGING FORTNIGHTLY ONLY

Total Cost per year

Total Cost per fortnight Tick the administration fee applicable

[ ] Administration fee $8.67 - no reportable benefits apply [ ] Administration fee $9.70 reportable benefits apply

v If you would prefer to pay the administration fee in full on commencement please completed the payment authority below. PAYMENT AUTHORITY FOR ANNUAL ADMINISTRATION FEE PAID UP FRONT

[ ] Full reportable benefits $252.20 cheque attached payable to Remuneration Services (Qld) Pty Ltd [ ] Full reportable benefits $252.20 money order attached payable to Remuneration Services (Qld) Pty Ltd [ ] Non reportable benefits $225.42 cheque attached payable to Remuneration Services (Qld) Pty Ltd [ ] Non reportable benefits $225.42 money order attached payable to Remuneration Services (Qld) Pty Ltd [ ] Payment by credit card (please circle one) Bankcard Mastercard Visa

Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiry Date ___/___ Cardholder s Name_________________________________________

Cardholder s Signature______________________________________

Date ___/___/___

This document will be a Tax Invoice for GST when you make the payment. Please make a COPY of this form when completed and keep as your tax invoice.

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Nominated Benefits

Please nominate below the benefits you wish to package to and provide the relevant substantiation. Please show the expected payment amount and also the amount you will package to pay for each benefit, shown as a

fortnightly and annual figure. Please specify if calculations are or are not based on 26 fortnights. Aged Care and Disability Costs

Name of Aged Care /Disability Services Provider ___________________________________________________

Payment Amount $______________

Option 1 - Irregular or single payments only.

Please Attach: Ø Submit invoice for payment; or

Ø Submit the invoice and receipt for reimbursement.

Option 2 Regular direct payment

Payments to be made: [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only

[ ]There is a regular due date (eg on 15th of each month). Please give details:

___________________________________________________ Please Attach: Ø Submit invoice with your application for RemServ to pay this benefit

directly to the supplier.

Ø Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT).

Option 3 - Regular direct debit to be reimbursed.

Please Attach: Ø Please attach invoice and bank statement showing direct debits and theDirect Debit Reimbursement Request on page 36.

Total amount to package per year for this benefit

Amount to package per fortnight for this benefit

Airport Lounge Membership

[ ] I will submit the invoice for payment

[ ] I will submit the invoice and receipt for reimbursement.

Please Attach: Ø The Expense Payment Benefit Declaration on page 37. Total amount to package per year

for this benefit Amount to package per fortnightfor this benefit

Briefcases, Calculators, Tools of Trade and Protective Clothing [ ] I will submit the invoice for payment

Please Attach: Ø The Expense Payment Benefit Declaration on page 37. Total amount to package per year for

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 7 Car Parking

Payment Amount $___________

Option 1 - Pay deduction to be reimbursed

Please Attach: Ø Provide two current pay slip to show this regular deduction for reimbursement.

Option 3 Regular direct payment to supplier

_______________________________________________ Please Attach: Ø Submit invoice with your application for RemServ to pay this benefit

directly to the supplier

Ø Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Total amount to package per year

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Child Care

Please tick one

The child care provider is [ ] In house [ ] Non-employer owned

Option 1 - Regular direct payment to supplier

________________________________________________________ Name of service provider :___________________________________ Lodgement Reference Code : __________________________________ Account Name:

__________________________ BSB : __ __ __-__ __ __ Account Number:

__ __ __ __ __ __ __ __ __

Amount to be paid to this account $___________

Please Attach: Ø Submit copy of invoice with your application.

Ø Submit supplier letter or statement confirming account details if direct payment is required.

Option 2 - Single Payment/Reimbursement Upon Request .

Ø A copy of the invoice and bank statement showing the direct debit and theDirect Debit Reimbursement Request on page 36.

Option 3 - Pay deduction or direct debit to be reimbursed

Please Attach:

[ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only

Payment Amount $___________

Ø Provide current pay slip to show this regular deduction for reimbursement.

Total amount to package per year for

this benefit Amount to package per fortnightfor this benefit

Child Care Declaration: I, ... (Employee Name)

understand that by salary packaging, I may be ineligible or have a reduced claim to the Child Care Benefit (CCB).

Signed: .. . Date: . / .. / ..

For more information regarding Child Care Benefit

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 9 Club/Association Membership Subscriptions (non work related)

[ ] I will submit the invoice(s) for payment

[ ] I will submit the invoice(s) and receipt(s) for reimbursement.

Disability / Income Protection Insurance 1. Name of Disability / Income Protection Insurer ____________________________________________ Account/Policy Number_________________________

2. Name of Disability / Income Protection Insurer ____________________________________________ Account/Policy Number

__________________________

Payment Amount $ __________ Payment Amount $__________

Payments to be made: [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only

_____________________________________________________ Please Attach: Ø Submit invoice with your application for RemServ to pay this benefit

Option 3 - Regular direct debit to be reimbursed.

Please Attach: Ø Please attach invoice and bank statement showing direct debit amounts and theDirect Debit Reimbursement Request on page 36.

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Financial Adviser Fees

Payment Amount $___________

Option 1 -Irregular or single payments only.

Option 2 - Regular direct payment

Payments to be made: [ ] Fortnightly [ ]Monthly [ ] Quarterly

Please Attach: Ø Submit invoice with your application for RemServ to pay this benefit directly to the supplier

Ø Submit copy of supplier document showing account details if this benefit can be paid directly by electronic funds transfer (EFT). Total amount to package per year for

this benefit

Health Insurance

Please note that the amount you package must NOT include the 30% the Government pays as a rebate.

1.Name of Fund _______________________________ 2.Name of Fund _______________________________ Membership Number ___________________________ Membership Number ___________________________

Payment Amount $______________ Payment Amount $______________

Option 1 - Pay deduction to be reimbursed

Please Attach: Ø Provide two current pay slip to show this regular deduction for reimbursement.

Option 2 - Irregular payments

_____________________________________________________ Please Attach: Ø Submit invoice with your application for RemServ to pay this benefit

Option 4 Regular direct debit to be reimbursed

Please Attach: Ø Please attach a copy of your invoice/statement and complete the Direct Debit Reimbursement Request on page 36.

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 11 HECS Fees

Payment Amount $___________

Option 1 Irregular or single payments only.

Ø Submit invoice for payment; or

Payments to be made:

HECS EFT Code:

_____________________________________________________ __________________________________________

Please Attach: _Ø _{Submit University invoice or ATO remittance with your application}

Option 3 - Reimbursement

Please Attach: _Ø _{Submit proof of payment to University or ATO with your application.} Total amount to package per year for

this benefit

You must provide your 18- character HECS EFT code for direct payments. Your HECS EFT code is printed on the top right of your HECS information statement just below your tax file number. If you cannot find your HECS EFT code, ring the ATO on 1300 650 225.

Make sure you provide the HECS EFT code accurately as it is used to correctly identify your account and the type of payment being made.

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Home Mortgage

Option 1 Regular direct payment (may be to two accounts if applicable)

Payment Frequency [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Upon Request

[ ]There is a regular due date (eg on 15th of each month). Please give details: ____________________________________________________

[ ]If weekly please specify day:_____________________________

---Your application/contract number may not be your loan account number. Please check with your bank. Credit union or building society member number (may be different from account number):

Name of bank or lending institution:

Account Name:

__ __ __ __ __ __ __ __ __

Amount to be paid to this account $___________

Account Name:

__ __ __ __ __ __ __ __ __

Amount to be paid to this account

$___________

Please Attach: Ø Copy of loan statement(s) or bank letter confirming loan account name(s) and number(s).

Ø The completedLoan Draw Down Declaration on the next page must be included if packaging this benefit.

Option 2 Regular reimbursement for direct debit (may be to two accounts if applicable)

Payment Frequency [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Upon Request

[ ]There is a regular due date (eg on 15th of each month). Please give details: ____________________________________________________ [ ]If weekly please specify day:___________________________________

---If your direct debit will

increase in the future, you will need to forward a new bank statement to substantiate the new amount.

Credit union or building society member number (may be different from account number):

Account Name:

________________________ BSB : __ __ __-__ __ __ Account Number:

__ __ __ __ __ __ __ __ __

Amount to be reimbursed to this account $_________

Account Name:

________________________ BSB : __ __ __-__ __ __ Account Number:

__ __ __ __ __ __ __ __ __

Amount to be reimbursed to this account $________

Please Attach: Ø Copy of the bank statement(s) for account shown above with bank account name and number showing the regular direct debit from the account and loan statement. Evidence of the account numbers of both accounts from the lending institution should be provided.

Ø BSB must be provided

Ø The completedLoan Draw Down Declaration on the next pagemust be included if packaging this benefit.

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LOAN DRAW-DOWN DECLARATION

I, ... (Employee Name) advise that:

a) I have a loan facility under which I am the recipient of loan funds by way of housing mortgage;

b) This facility enables funds to be redrawn under various circumstances provided for in the applicable housing mortgage documentation;

As a result, I hereby declare that where Remuneration Services (Qld) Pty Ltd makes payment of any amount, under the salary package arrangements available to me, in satisfaction of any liability arising under the aforementioned housing mortgage, I will not seek to obtain a subsequent draw-loan of any funds so paid unless;

i. Such funds are also used for a valid purpose which is itself available to me under the salary package arrangements associated with Remuneration Services (Qld) Pty Ltd; and

ii. Sufficient documentation is provided to Remuneration Services (Qld) Pty Ltd in order to substantiate such validity.

Declarant: Witness:

Signed: .. . Signed: .. .

Name: .. . Name: .. .

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Home Office Expenses

Please Attach: Ø The completedExpense Payment Declaration on page 37. Total amount to package per year for

this benefit

Mobile Phones (predominantly business) [ ] I will submit the invoice(s) for payment

[ ] Regular reimbursement of direct debit. Please attach copy of invoice andDirect Debit Reimbursement Request on page 36.

Please Attach: Ø A copy of invoice and Expense Payment BenefitDeclaration on page 37. Total amount to package per year for this

benefit

Motor Vehicle Novated Lease

Name of Financier __________________________________________________________________________ Financier s address _________________________________________________________________________ _________________________________________________________________________________________

Capital Cost of Vehicle $___________

Estimated kilometres per year:

Statutory fraction [ ] 7% [ ] 11% [ ] 20% [ ] 26% Lease Commencement Date: Lease Expiry Date:

Registration Number (when available) Opening Odometer Reading (when available)

Model: ___________________ Make: ___________________ Colour (when available): __________________

Due date: _{____________________ day of each month.}

Total amount payable to financier each MONTH $__________________

Please Attach:

Ø Copy of finance schedule or quotation if provided and the Deed of Novation.

Ø Please forward the payment book if your financier requires payment using this method.

Ø Copy of financial adviser s worksheet/calculations

If your novated lease agreement does not include fuel, registration and insurance, you must package this as a separate item and include the details in the next section. A fuel card will be issued to you. See the Novated Lease Salary Packaging Booklet for further details.

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 15 Motor Vehicle Operating Costs for Novated Lease

Registration

Maintenance

Fuel

I am packaging a novated lease and will package a fuel card. [ ] Fuel card will be provided with my lease through the financier.

[ ] I require a RemServ issued BP fuel card and will submit details below Total amount to package per year for

Please supply me with a BP fuel card for the vehicle listed below.

Fuel cards can only be issued where all required information is provided. Please submit the BP Fuel Card Confirmation of Details form when you have the required information if these details are not yet available. REGISTRATION NO: MAKE: MODEL: COLOUR: FUEL TYPE:

STARTING ODOMETER READING:

________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

I understand that my BP fuel card is a credit card only and payment of the account is ultimately my responsibility. It is understood that Remuneration Services will undertake to pay my account as part of my salary packaging agreement. If at any time my salary packaged funds are insufficient to cover the amount due, it is agreed that Remuneration Services will pay the shortfall on my behalf and any amount paid will be reimbursed to

Remuneration Services by me.

It is further agreed and acknowledged that if at any time I cease salary packaging with Remuneration Services any amount owing on my BP fuel card may be paid by Remuneration Services out of my trust fund and if my trust fund is insufficient to clear the amount owing on my BP fuel card, any shortfall will be reimbursed to Remuneration Services by me.

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Motor Vehicle Operating Costs for Novated Lease Cont.... Insurance

Name of Insurer: ____________________________________________________________________________

Payment Amount: $___________

Option 1 Irregular or Single payments only.

Option 2 Regular direct payment to insurer

Option 3 Regular direct debit to be reimbursed

Please Attach: Ø Please attach copy of invoice and bank statement showing direct debits andDirect Debit Reimbursement Request on page 36. Total amount to package per year for

this benefit Amount to package per fortnightfor this benefit FBT Provision Amount

this benefit Amount to package per fortnightfor this benefit GST on ECM component

Total Motor Vehicle Novated Lease and Novated Lease Operating Costs (inclusive of tax provisions)

Total amount to package

per YEAR Amount to packageper FORTNIGHT

Pre Tax Amounts

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 17 Motor Vehicle Operating Costs (not Novated Lease)

Registration

Maintenance

[ ] I will submit the invoice(s) and receipt(s) for reimbursement. [ ] I will submit the tax invoice (s) for direct payment

Fuel

[ ] I will submit the tax receipts for reimbursement. [ ] I will submit the tax invoice (s) for direct payment

[ ] I require a fuel card and will submit the required information listed below Total amount to package per year for

I wish to be supplied with a BP fuel card for the vehicle listed below

Fuel Cards can only be issued where all required information is provided. Please use theBP Fuel Card Confirmation of Details form once you have the required information.

REGISTRATION NO: MAKE:

MODEL: COLOUR: FUEL TYPE:

STARTING ODOMETER READING:

________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

I understand that my BP fuel card is a credit card only and payment of the account is ultimately my responsibility. It is understood that Remuneration Services will undertake to pay my account as part of my salary packaging agreement. If at any time my salary packaged funds are insufficient to cover the amount due, it is agreed that Remuneration Services will pay the shortfall on my behalf and any amount paid will be reimbursed to

Remuneration Services by me.

It is further agreed and acknowledged that if at any time I cease salary packaging with Remuneration Services any amount owing on my BP fuel card may be paid by Remuneration Services out of my trust fund and if my trust fund is insufficient to clear the amount owing on my BP fuel card, any shortfall will be reimbursed to Remuneration Services by me.

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Motor Vehicle Operating Costs (not Novated Lease) Cont... Insurance 1.Name of Insurer: ________________________________________ Payment Amount: $____________ Insurance 2. Name of Insurer: ___________________________________________ Payment Amount: $____________ Option 1 - Irregular or single payments only.

Option 2 - Regular Direct payment to insurer

_______________________________________________ Please Attach: Ø Submit invoice with your application for RemServ to pay this benefit

Option 3 Regular direct debit to be reimbursed

Notebook/ Laptop Computers, Electronic Diaries and Packaged Software

Payment Amount $___________

_______________________________________________

Option 1 - Single payments only.

Option 2 Regular reimbursement of up-front purchase

Please Attach: Ø Invoice and proof of payment

Option 3 Regular direct payment to hire purchase / leasing provider

Please Attach: Ø Please submit invoice/ hire purchase/ lease payment details with your application.

Option 4 Reimbursement of direct debit to hire purchase /leasing provider

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 19 Personal Loan Repayments

Name of Lender: ____________________________________________________________________________ Payment Frequency

[ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly

[ ]There is a regular due date (eg on 15th of each month). Please give details:

____________________________________________________________________________

Payment Amount $___________

Option 1 Personal Loan Payment is to be made directly to this account: Your application/contract number

may not be your loan account number. Please

check with your bank.

Credit union or building society member number (may be different from account number):

__________________________

Account Name:

__ __ __ __ __ __ __ __ __

Serial Number (if Applicable ___ ___ ___ ___ ___ ___ Amount to be paid to this account

$___________

Account Name:

__ __ __ __ __ __ __ __ __

Serial Number (if Applicable ___ ___ ___ ___ ___ ___ Amount to be paid to this account

$___________

Please Attach: Ø Copy of loan statement or bank letter confirming loan account name and number or payment slip from the loan payment book showing account name and number.

Option 2 Personal loan direct debit payment to be reimbursed Your application/contract number

may not be your loan account number. Please

check with your bank.

Credit union or building society member number (may be different from account number):

__________________________

Account Name:

__ __ __ __ __ __ __ __ __

Amount to be paid to this account

$___________

Account Name:

__ __ __ __ __ __ __ __ __

Amount to be paid to this account

$___________

Please Attach: Ø Copy of the bank statement(s) for account shown above with bank account name and number showing the regular direct debit from the account.

Ø Copy of loan statement or bank letter confirming loan account name and number.

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Private Travel

this benefit Amount to package per fortnight forthis benefit

Professional Memberships/ Subscriptions [ ] I will submit the invoice(s) for payment

[ ] Regular reimbursement of direct debit. Please attach copy of invoice andDirect Debit Reimbursement Request on page 36.

[ ] Reimbursement of payroll deductions provide two current payslips showing these deductions.

Please Attach: Ø TheExpense Payment Declaration onpage 37 must be included if packaging this benefit.

this benefit Amount to package per fortnight forthis benefit

Rental own home

Name of Agent/ Landlord _____________________________________________________________________ Agent/Landlord address _____________________________________________________________________ Agent/Landlord contact telephone _____________________

Payment Amount $___________

Regular payments to be made:

[ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only [ ]There is a regular due date (eg on 15th of each month). Please give details:

Option 1 Pay rent directly to agent/landlord s account

Client reference number if required by landlord._________________________ Account Name:

BSB : __ __ __-__ __ __ Account Number:__ __ __ __ __ __ __ __ __ Please Attach: Ø Letter on business letterhead from agent or a Landlords Declaration

confirming account details

Ø Copy of lease agreement (must be current)

Option 2 Home rental direct debit payment to be reimbursed

Please Attach: Ø Copy of the bank showing the regular direct debits from the account or a copy the the direct debit authority

Ø Copy of lease agreement (must be current), or a Landlord Declaration

Option 3 Direct payment to be reimbursed

Please Attach: Ø Copy of receipt

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LANDLORD/AGENT DECLARATION RemServ reimburses your rental payment

Use this form if you do not have a current formal tenancy agreement with your landlord or to provide other payment information in addition to your lease.

I, ... ... ... ... (Tenants Name)

of ... .. (Rental Property Address)

Declare that the above property is rented from ... ...under the rental tenancy act. (Landlord/Agent)

I confirm that the details for reimbursement of rent are as follows:

Bank BSB : ___|___|___ - ___|___|___ Account : __|___|___|___|___|___|___|___|___ The reimbursement amount is to be $ ____________________ per fortnight/month/quarter

I understand that the rent will continue to be reimbursed up to the date shown above and that I will be required to confirm an extension of the rental arrangement in writing to RemServ if I require rent reimbursement payments to continue.

I understand that any payment made to me by RemServ as a rent reimbursement will not comply with Australian Taxation Office salary packaging if I am not paying an equal or greater amount in rent to the landlord or agent. Signature: ...Date: . / .. / ..

---LANDLORD OR AGENT TO COMPLETE

I ... ., Phone number (Landlord/Agent Name)

Declare that the abovenamed is currently residing in the rental property owned/managed by myself , at the abovenamed property.

at... ... (Rental Property Address)

This rental arrangement is current up to

(Date)

Rent amount paid $... per fortnight/month/quarter

Signature: ...Date: ... Witnessed this ________________ day of __________________________, 20____

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LANDLORD/AGENT DECLARATION RemServ pays your rent direct to your landlord

Use this form if you do not have a current formal tenancy agreement with your landlord or to provide other payment information in addition to your lease.

I, ... ... ... ... (Tenants Name)

of ... .. (Rental Property Address)

Declare that the above property is rented from ... ...under the rental tenancy act. (Landlord/Agent)

The salary packaged contribution amount is to be $ ____________________ per fortnight/month/quarter

I understand that I am required to advise RemServ when this arrangement ceases. I understand that RemServ is not responsible for the return of payments made to a landlord or agent after the rental arrangement has ceased if advice of the cessation has not been provided to RemServ

I understand that the rent will continue to be paid up to the end date shown below and that I will be required to confirm an extension of the rental arrangement to RemServ if I require rental payments to continue.

Signature: ...Date: . / .. / ..

---LANDLORD OR AGENT TO COMPLETE

I ... ., Phone number (Landlord/Agent Name)

Declare that the abovenamed is currently residing in the rental property owned/managed by myself , at the abovenamed property.

at... ... (Rental Property Address)

This rental arrangement is current up to

(Date)

Rent amount paid $... per fortnight/month/quarter I confirm that the details for reimbursement of rent are as follows:

Bank BSB : ___|___|___ - ___|___|___ Account : __|___|___|___|___|___|___|___|___ OR

I confirm that the rent is payable by cheque, made out to: ... And posted to this address: ... ... Signature: ...Date: ... Witnessed this ________________ day of __________________________, 20____

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 23 Savings/ Investment Schemes (non superannuation)

Name of Investment Company _________________________________________________________________ Investment company address __________________________________________________________________ Investment Company contact number: _________________

Policy Number _____________________ Payment Amount $___________

Option 1 Regular direct payment to investment fund

[ ]There is a regular due date (eg on 15th of each month). Please give details: _______________________________________________

Please Attach: Ø Submit invoice with your application for RemServ to pay this benefit directly to the supplier

Ø Please attach the prospectus AND policy document/invoice which include payment information.

Ø TheSavings and Investment Declaration must be included if packaging this benefit.

Option 2 - Regular direct debit to be reimbursed

Please Attach: Ø Copy of the bank statement showing the regular direct debit from the account.

Ø Please attach the prospectus AND policy document/invoice

Ø Please attachDirect Debit Reimbursement Request on page 36.

Ø TheSavings and Investment Declaration must be included if packaging this benefit.

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SAVINGS/INVESTMENT SCHEME DECLARATION

I, ... (Employee Name) advise that: I have chosen to package a savings/investment scheme contribution plan as part of my salary packaging. I confirm that this scheme meets the following terms:

It is a managed investment fund which is structured on a unitised basis.

The investment insurance product is provided by an approved life company and: i. Has a minimum term of not less than 10 years;

ii. Is held under a trust pursuant to which:

· The policy is not able to be terminated within 10 years;

· And the premiums paid on the policy are not able to be accessed, borrowed against or withdrawn within 10 years except in special circumstances involving serious financial difficulties suffered by the rulee;

iii. May provide for a payment in respect of death or disability;

iv. Is treated as paid up if the premium payments are discontinued for any reason and will be continued so that the policy will be in force for at least 10 years before the proceeds are paid out;

v. has no direct or indirect loan back arrangements attached to it.

I understand that if these terms are breached except under specific circumstances such as financial hardship, that the Australian Tax Office may consider the salary packaged amounts salary and subject to income tax or fringe benefits tax. I understand that if this occurs I am liable for the tax payable.

Declarant: Witness:

Signed: .. . Signed: .. .

Name: .. . Name: .. .

(25)

Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 25 Self Education Expenses

[ ] I will submit the invoice for payment

[ ] Regular reimbursement of direct debit. Please attach copy of invoice and bank statement showing direct debit payments

and

Direct Debit Reimbursement Request on page 36.

Please Attach: Ø The self educationExpense Payment Declaration must be included if packaging this benefit.

SELF EDUCATION EXPENSE BENEFIT DECLARATION

I, ... (Employee Name), declare that (show nature of expense eg telephone rental):...

.. .. ...

were provided to me by or on behalf of my employer during the period from .. ./ ../20 .. to ../ ../20 . And the expenses were incurred by me for the following purpose(s):

...

I also declare that the percentage of those expenses incurred in earning my assessable income was ...% I understand that this declaration is to apply to the above stated benefit and to any identical benefit* for a period of up to 5 years from the date of this declaration or until the stated percentage incurred in earning my assessable income decreases by more than 10 percent points. This declaration will also be revoked if another recurring expense payment fringe benefit declaration is provided in respect of a subsequent identical benefit.

Signed: .. .. .Date: . / .. / 20.

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Trauma/ Life Insurance Premiums 1. Name of Insurer __________________________________________ Insurer s address ____________________________ __________________________________________ Policy Number ______________________________ Payment Amount $____________ 2. Name of Insurer ___________________________________________ Insurer s address _____________________________ ___________________________________________ Policy Number _______________________________ Payment Amount $____________ Option 1 - Irregular or single payments only.

1. Name of Insurer __________________________________________ Insurer s address ____________________________ __________________________________________ 2. Name of Insurer ____________________________________________ Insurer s address ______________________________ ____________________________________________ Please Attach: Ø Submit invoice for payment; or

Payment to be made: [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual only

Option 3 - Regular reimbursement of direct debit.

Please Attach: Ø Please attach copy of invoice and bank statement showing direct debit payments and theDirect Debit Reimbursement Request on page 36.

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Application continues on the next page Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 27 Utilities

(please submit additional copies of this page is packaging more than one payment type for different utilities)

Please Attach Ø Submit invoice for payment; or

Option 2 Regular direct payment to supplier

Name of Payee/Supplier_______________________________________________________________________ Payments to be made: [ ]Weekly [ ] Fortnightly [ ]Monthly [ ] Quarterly [ ] Annual

only

____________________________________________________

Payment Amount $___________

Please Attach: Ø Please submit invoice with your application.

Option 3 - Reimbursement of direct debit to supplier

Name of Payee/Supplier_______________________________________________________________________ Please Attach: Ø Please attach copy of invoice and bank statement showing direct

debits andDirect Debit Reimbursement Requeston page 36. Total amount to package per year for

Work Related Travel Expenses [ ] I will submit the invoice(s) for payment

Please Attach: Ø TheExpense Payment Declaration on page 37 must be included if packaging this benefit.

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Financial Adviser Form

State Library of Queensland

Client Details

Employee Name: ... Employee Payroll ID No: ... I confirm that the above mentioned employee has attended the required salary packaging consultation and has received financial advice in respect of their individual salary packaging circumstances.

Financial Adviser/Consultant Details

Name:... ... Contact Number:... Email:... .. Fax Number:... Organisation: ... Postal Address:... I confirm that the above mentioned employee has :

1. Had all fees disclosed to them Yes / No 2. Received a statement identifying the effect on take home pay Yes / No 3. Had the reimbursement process explained where necessary Yes / No 4. Received a copy of all documents to be lodged Yes / No 5. Received a car comparison where applicable Yes / No The following pre tax amounts are to be packaged by the employee:

$____________ per fortnight (including Administration Fee) to RemServ (do not include super amounts here), $____________ per fortnight QSuper Voluntary Contributions, and

___________% per fortnight QSuper Standard Contributions.

The employee has also chosen to package $____________ per fortnight under the post tax Employee Contribution Method.

Please specify basis of calculations are or (are not based on 26 fortnights.)

o

Calculations are based on 26 fortnights in the year.

o

Calculations are based on ____________ fortnights.

The benefit items selected by the employee are in accordance with the Arrangement and the totals do not exceed the 50% of superannuatable fortnightly salary.

This document must be attached when documentation when submitted to Remuneration Services (Qld) Pty Ltd.

Financial Adviser Signature:... ... Date:.../.../20... Dealer/Financial Adviser License No or CPA or CA number :...

(29)

Salary Packaging Participation Agreement

State of Queensland

This Agreement is BETWEEN:

THE STATE OF QUEENSLAND through the State Library of Queensland (the Employer), AND ______________________________________________________________(the Employee). Print Employee name

The State Library of Queensland has elected to participate in SOA 250 by which the State Library of Queensland offers the Employee the option to participate in salary packaging.

RemServ has been appointed by Queensland Government to administer the State Library of Queensland s salary packaging arrangements. The salary packaging will be administered by RemServ in consultation with Queensland Purchasing and DIR.

The State Library of Queensland and Employee agree on the following terms and conditions:

1. The Employee may make Salary Packaging arrangements only on a prospective basis. 2. Salary Packaging will be paid fortnightly by the State Library of Queensland.

3. The employee may elect to avail of one or more of the benefit items approved by Queensland Government for salary packaging purposes, providing the aggregate gross value of the items does not exceed 50% of the projected total salary for the package year.

4. (a) The participation of the Employee in salary packaging shall be at no cost to the Employer. (b) The Employee (i) indemnifies and shall keep indemnified the Employer its servants and agents from and against all actions, proceedings, claims, demands, costs, losses, damages, liabilities and expenses which (A) may be brought against or made upon the Employer by the Employee or any other person; or (B) the Employer may incur, sustain, expend or be put to, by reason of or arising out of the participation of the Employee in salary packaging; and (ii) releases and discharges the Employer from any actions, proceedings, claims or demands which but for the provisions hereof may be brought against or made upon the Employer by the Employee by reason of or arising out of the participation of the Employee in salary packaging.

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6. Any additional costs incurred as a result of termination or cessation of the Employee s salary package, shall be the responsibility of the Employee. The State Library of Queensland may recover such costs from the Employee as a debt due.

7. (a) If any part of the Salary Package has been paid in advance by the State Library of

Queensland or RemServ and this agreement is terminated for whatever reason, the amount which has been paid which is more than the entitlement at the date of termination, shall be deducted from the Employee's termination of employment payment from the Agency in the calculation of all statutory leave entitlements by the Agency.

(b) Where there is a statutory obligation on the Employee to pay entitlements to the State Library of Queensland, the Employee undertakes to pay immediately the equivalent of such amounts to the State Library of Queensland in reduction of any amount owing under this agreement.

8. In the event of the Employee's termination of employment with the State Library of Queensland for any reason whatsoever, the calculation of all statutory leave entitlements such as long

service and recreation leave shall be at the rate applicable to the Employee's substantive salary.

9. On completion of the package year the balance in the fund will be rolled over to the next package year.

SALARY PACKAGE COMPONENTS and REVIEW

10.

(a) The components of the Salary Package may be changed as near as practical but prior to the completion of the package year which shall end on at 31st March of each year, with the consent of the State Library of Queensland.

(b) However, under any of the following defined circumstances: - separation;

- divorce; - ill health;

- extended leave including parental leave;

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Application continues on the next page

Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 31

the Employee shall have the right to initiate a review of the components of the Salary Package prior to the completion of the package year.

11. In the event of exceptional or unintended circumstances, the State Library of Queensland may agree to prospectively vary the components of the Employee s Salary Package. A single change per year will be permitted without penalty. An additional fee of $50 may, at the discretion of RemServ, be charged for each time a change is made to the package. This fee will be payable to RemServ by the Employee.

12. (a) In the event that there are changes relating to

(i) Fringe Benefits Tax (FBT) legislation;

(ii) the introduction of any State equivalent to Fringe Benefits Tax legislation; or (iii) the way in which any Fringe Benefits Tax legislation is interpreted;

this agreement will be renegotiated in accordance with the provisions of SOA 250. (b) Until such time as this agreement is renegotiated following changes to the FBT status

of the State Library of Queensland, any FBT liability from this agreement will be the responsibility of the Employee and the Employee indemnifies Queensland

Government in respect of any FBT liability borne by Queensland Government arising out of this agreement.

FINANCIAL ADVICE

13. The Employee acknowledges that it is a requirement of Queensland Government that independent financial advice is sought prior to the participation in full salary packaging.

ADMINISTRATION

14. The fees to be charged by RemServ for administering salary package payments made under this

agreement are payable by the Employee to RemServ. The total fee amount includes government rebates.

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16. The Employee acknowledges that if packaging a novated lease of a motor vehicle, a fuel card must be packaged either directly through the motor vehicle financier, or with RemServ.

CONFIDENTIALITY AND ACKNOWLEDGEMENT

17. The terms of this agreement replace all previous agreements between the Employee and the State Library of Queensland in relation to salary packaging and are to remain confidential between said parties. The terms and conditions agreed between the Employee and the State Library of Queensland herein relate only to the Employee s Salary Package.

18. It is acknowledged and accepted by the Employee that the State Library of Queensland and RemServ are not liable for taxation or any other liabilities, judgments, penalties or outcomes suffered or incurred by the Employee as a result of entering into this salary package

arrangement and the Employee indemnifies the State Library of Queensland and RemServ in respect of any such taxation, liability, judgment, penalty or outcome that the State Library of Queensland and RemServ may suffer.

19. In accepting this offer of salary packaging

(a) the Employee confirms that the benefit items selected for the package are legitimate expense items; and

(b) are to be paid from funds provided by the Employee under the salary package arrangement.

20. In the event of appointment, promotion, assignment, redeployment, transfer or other process to another Government Agency entity, the Employee

(a) shall be subject to any salary packaging arrangements applying to the new Government Agency; and

(b) undertakes to take all necessary steps to comply with those arrangements; (c) must immediately notify RemServ.

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Application continues on the next page

Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 33

PARTICIPATION OBLIGATION AND CESSATION

22. The Employee was under no obligation to participate in salary packaging, and entered into this agreement of his/her own free will.

23. The Employee may elect at any time to cease salary packaging by giving at least twenty-one (21) days notice in writing to RemServ. If cessation occurs within a 12 month period from the Employee s

anniversary date, the administration fee payable by the Employee shall be, where the date of cessation is -(a) 8 months or less of package year - 75% of annual fee amount ; or

(b) 9-12 months of package year - 100% of annual fee amount . The administration fee must be paid prior to the date of cessation.

24. Any funds available on termination or cessation of participation in the Salary Package cannot be taken as a cash payment. Funds must be utilized for benefit payments or be returned to payroll by RemServ to be paid as salary and taxed accordingly.

25. (a) The Employee may recommence salary packaging only with the agreement of the State Library of Queensland;

(b) a reintroduction fee of $50 may, at the discretion of RemServ apply. This fee will be payable to RemServ by the Employee.

26. The State Library of Queensland may terminate (a) a novated lease; and

(b) that part of this agreement which relates to a novated lease, where the Employee

(c) ceases employment; or (d) is not entitled to salary. 27.

(a) At the request of the State Library of Queensland, this agreement may be varied prior to the anniversary of the commencement date.

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INTERPRETATION

28. In this Agreement, unless the context otherwise indicates

Salary Packaging means the arrangement, which allows salary to be taken as benefits before

tax.

RemServ means Remuneration Services (Qld) Pty Ltd, ABN 4609 317 3089 at Level 13, 60

Edward Street, Brisbane.

Benefit Items means payments made by the Employer on behalf of the Employee for benefits in

lieu of salary.

SOA 205 means Standing Offer Arrangement 250 let by Queensland Purchasing to RemServ.

Queensland Purchasing means that part of the Department of Public Works known as

Queensland Purchasing.

DIR means the Department of Industrial Relations.

EMPLOYEE

I have read and understood and accept the offer of salary packaging on the terms and conditions herein.

Name ... ... ... (please print)

Signed... .. Date: ..../ ..../ ... .

AUTHORISED QUEENSLAND GOVERNMENT OFFICER

(RemServ will arrange for this signature.)

Name ... ... ... (please print)

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Remuneration Services (Qld) Pty Ltd Call centre 1300 30 40 10 Page 35 Completion of application

Your application should include the following details

q

Your application has all the personal and superannuation details requested on pages 2 - 5

q

All the benefits you wish to package are listed on the form from pages 6 - 27

q

You have all the required substantiation documentation attached as outlined for each selected benefit.

q

You have attached the declaration forms (where applicable).

q

You have attached copies of the Direct Debit Reimbursement Request (page 36) where applicable.

q

You have signed the application form on page 2.

q

You have included the Financial Adviser Form, signed by your adviser, which shows the adviser or registration number on page 28.

q

You have included the signed Participation Agreement (RemServ will arrange the employer signature on your behalf) on page 28.

Your application (original forms, not copies) and all the attachments should be sent to: Remuneration Services (Qld) Pty Ltd

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Direct Debit Reimbursement Request

State Library of Queensland

In some instances, the application form does not give room for a direct debit instruction. This form is provided for those instances where normal payslip or invoice / receipt reimbursement does not apply.

Name of Benefit paid by direct debit___________________________________________________ (eg Professional Memberships and Subscriptions)

Payments to be made

Bank Account for Reimbursements to be paid to

Bank BSB : ___|___|___ - ___|___|___ Account : ___|___|___|___|___|___|___|___|___

Please attach the appropriate substantiation:

· Copy of supplier s statement or invoice where applicable

· Copy of the bank or supplier s direct debit confirmation or bank statement(s) showing the regular direct debit from the account.

· Any relevant declaration forms

I understand that I must notify RemServ as soon as the direct debit ceases or reduces in amount.

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Remuneration Services (Qld) Pty Ltd Call centre 1300 30 4010 Page 37

Expense Payment Benefit Declaration

State Library of Queensland

I, ... declare that (Employee Name)

(show nature of expense eg telephone rental): ...

... ...

were provided to me by or on behalf of my employer during the period from ____ /_____/_____

to _____ /_____/______ and the expenses were incurred by me for the following purpose(s): ... ... ... ... ... I also declare that the percentage of those expenses incurred in earning my assessable income was ... %

I understand that this declaration is to apply to the above stated benefit and to any identical benefit* for a period of up to 5 years from the date of this declaration or until the stated percentage incurred in earning my assessable income decreases by more than 10 percentage points. This declaration will also be revoked if another recurring expense payment fringe benefit declaration is provided in respect of a subsequent identical benefit.

Signature: ... Date: ...

*Note: Identical benefits are ones which are the same in all respects except for any differences that are minimal or

insignificant, or that relate to the value of the benefits, or that relate to change in the deductible proportion of 10 percentage or less.

This declaration is required if packaging: Professional Memberships and Subscriptions Airport Lounge Membership

Briefcases, calculators, tools of trade, and protective clothing Home Office Expenses