Subcontractor'S Statement Regarding Workers Compensation, Pay-Roll Tax And Remuneration Form printable pdf download

SUBCONTRACTOR’S STATEMENT

REGARDING WORKERS COMPENSATION, PAY-ROLL TAX

AND REMUNERATION (Note 1)

New South Wales

Workers Compensation

Pay-roll tax

Remuneration

s175B Workers Compensation Act 1987

Part 5B s31G-31J Pay-roll Tax Act 1971

ss127, 127A Industrial Relations Act 1996

Sub Contractor: _______________________________________ ABN: ________________________

(Business name)

of __________________________________________________________________________________

(Address of subcontractor)

has entered into a contract with_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Note 2)

(Business name of principal contractor)

ABN: ______________________ For work between:

and

(Note 3)

Date

and/or Payment Claim Details: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Note 4)

Nature of contract work: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Note 5)

DECLARATION

I, _________________________________ a Director of / a person authorised by the subcontractor on whose behalf this

(delete as appropriate)

declaration is made, hereby state that the abovementioned subcontractor:

Is either

A sole trader or partnership without workers or subcontractors

(Note 6)

Has and will maintain in force valid workers compensation insurance, policy _______________________

(Policy Number)

held with ______________________________________ as indicated on the attached Certificate of

(Insurance Company)

Currency dated ___________________, in respect of work done in connection with the contract, during

any period of the contract and has paid all workers compensation insurance premiums payable in

connection with the contract

(Note 7)

Is not

also a principal contractor in connection with the work under contract

(Note 8)

Has

Has not

been given a written statement by subcontractors in connection with the work.

Is not

required to be registered as an employer under the Pay-roll Tax Act 1971 ________________.

(Pay-roll tax client No.)

Has paid all pay-roll tax due in respect of employees who performed the work for the principal contractor, as

required at the date of this statement

(Note 9)

Has paid all remuneration payable to relevant employees, for work done under the contract during the period

outlined above

(Note 10)

Signature _________________________________ Full Name _______________________________

(please print)

Position/Title ______________________________

Dated _______________________________

WARNING

• Any subcontractor, who knowingly provides a principal contractor with a written statement that is false, is guilty of an

offence (Maximum penalty 100 units or $11,000).

• Any written statement will not relieve the principal contractor of liability if, at the time the written statement was provided,

the principal contractor believed the written statement to be false.

• The principal contractor must retain a copy of any written statement for a period of not less than five years (Pay-roll tax),

six years (Remuneration) or seven years (Workers compensation).

• This statement must be accompanied by the relevant Certificate of Currency to comply with section 175B of the Workers

Compensation Act 1987

Subcontractor'S Statement Regarding Workers Compensation, Pay-Roll Tax And Remuneration Form

Related Articles

Related forms

Related Categories