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Salary sacrifice claim form

Use this form to make one or more salary sacrifice claims. Fill in the details, accept the certification and sign — you can then download the completed form.

1

Claim details

A maximum of three items can be claimed on this form.

Item 1

2

Deduction request

Spreading a deduction over multiple pay cycles is subject to PayMe approval.

3

Certification

I declare that the above expense(s) is directly related to my work. I understand and acknowledge that:

  1. I am wholly responsible for this salary sacrifice claim.
  2. I am responsible for obtaining independent financial advice regarding the salary sacrifice of this item. PayMe accepts no liability should I fail to seek financial advice or for any financial advice I have independently sought.
  3. PayMe accepts no liability should I incur additional income tax or other costs, now or in the future, as a result of this salary sacrifice claim.
  4. I agree to reimburse PayMe the full cost of any Fringe Benefits Tax liability or penalty incurred as a result of this salary sacrifice claim.
  5. If my contract terminates before the full amount is able to be salary sacrificed, any outstanding amount will be settled in my final pay.

Please note: This expense should not be claimed again in your personal income tax return, as the ATO would consider it to be double-dipping.

4

Your details

Signature
5

Supporting documents

Attach receipts, invoices or quotes for the items you are claiming. They are sent securely to PayMe with your claim.

Questions? Call PayMe on 1800 082 006 or read the Salary Packaging Fact Sheet.

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