This Claim must be lodged within 28 days of the completion of the period for which you are claiming
Indigenous Wage Subsidy Claim for Payment and Tax
Invoice
Through submitting this form the employer declares that to the best of its knowledge, the details provided are true
and accurate. The Department of the Prime Minister and Cabinet may contact the employer after submission requesting
that the employer provide payroll advice for the whole claim period.
Career Development Assistance of up to $550 (including GST) is available to employers with IWS who enrol in an
accredited training course, obtain a ticket (such as Stop/Go), or License (such as forklift) within their first 26
weeks of employment.
For further information please refer to the IWS Guidelines available at www.employment.gov.au/iws
NOTE: Incomplete claim forms will not be processed.
Employer Information
1
Trading name
2
ABN
3
Postal address
Suburb
State
Post Code
The Department may contact your business in regards to this form. Who should the Department contact?
4
Mr
Ms
Mrs
Miss
Name
Position
Office Number
Facsimile Number
Mobile Number
Email Address
NB: All correspondence will be sent via email if provided.
1
5
Bank details for direct credit payment.
Wage Assistance is paid only by DIRECT CREDIT. It is VERY IMPORTANT that you supply us with the
correct details below. Payment to your account will be delayed if the details are incorrect.
Full name of the account
Bank name and branch
BSB Number
__ __ __ / __ __ __
Account Number
6
Employer’s declaration
I declare that to the best of my knowledge the details given in this form are true and complete, and I am
duly authorised to make this claim on behalf of my employer.
I am aware that under the Criminal Code Act 1995 (Cth) section 137.1 giving false or misleading information
is a serious offence.
I have evidence to substantiate this claim and, if required, I shall provide it to the Department
Signature of employer or authorised representative
Date
/
/
Printed name
Please make sure that the information on this form is true and correct, signed by employer and
employee(s), and return via:
Fax:
(02) 6276 9617
Email:
[email protected]
or Post:
Indigenous Wage Subsidy
Loc Code C50MA4
GPO Box 9880
Canberra City ACT 2600
For claims with multiple employees, please photocopy
page 3 and complete for each employee.
2
Employee Information
7
Full Name
8
IWS Ref No
9
Date of Birth
10
What is the period you are claiming for?
11
Is the position
Full Time - min 35 hours a week
(select one)
Part Time - min 15 hours a week
__/ __/ __ / __/ __/
13 weeks
26 weeks
Pro rata period
12
PLEASE provide hours worked each week for the period being claimed for part time employees
13
Have the hours changed since your application was approved?
Yes
What hours are now worked per week?
No
Date of change
14
What is the TOTAL GROSS amount you have paid the employee
over the period you are claiming for?
15
Hourly rate of pay
16
Does the employee still work for you? Yes
No
What date did the employee last work for you?
/
/
Why is the employee no longer employed by you?
17
How many days unpaid leave has the employee had – other than rostered or scheduled days off?
Please note: If the employee has taken more than 5 days unpaid leave, your subsidy will be reduced
th
for each day of unpaid leave after the 5 day.
18
Has the employee received any workers compensation payments?
Yes
19
What date did the Workers compensation start:
/
/
No
finish:
/ employee?
Do you wish to claim Career Development Assistance for/ this
(For further information please refer to the Indigenous Wage Subsidy Guidelines)
Yes
/
/
No
A recognisable receipt of payment MUST BE included for payment
When did this training commence?
/
/
Type of Training
Training Provider
20
Employee’s declaration
I declare that to the best of my knowledge the details given in this form are true and complete and I have
not been receiving the full rate of any Centrelink income support benefit or CDEP wages since I started
work.
PLEASE NOTE – Payslips for the period being claimed MUST be provided if not signed by employee
Signature of employee
Date
3