Withholding Declaration - Australian Government Taxation Office
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1
2
3withholding declaration
payer’s Copy
complete this declaration to authorise your payer to adjust the
the information in the completed Withholding declaration
amount withheld from payments made to you.
form must be treated in confidence.
you must provide, or have previously provided, your payer
with a completed Tax file number declaration (nat 3092)
read the instructions before completing this declaration.
n
(or Employment declaration or Annuity and superannuation
print neatly in BlocK letters and use a BlacK or
n
pension declaration completed before 1 July 2000), quoting
DarK Blue pen.
your tax file number or claiming an exemption from quoting it,
print
in the appropriate boxes.
X
before you can make a Withholding declaration.
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section a: payee’s declaration
to be completed by payee.
1
what is your name?
title:
mr
mrs
miss
ms
other
Family name
Given names
Day
month
year
2
what is your date of birth?
see ‘privacy of information’
on the inside front cover of the
instructions.
3
what is your tax file number (tfn)?
if you have not provided your tFn, indicate if any of the following reasons apply:
i have lodged a
i am claiming an exemption
i am claiming an exemption because i am under
18 years of age and do not earn enough to pay tax.
tFn application.
because i am a pensioner.
4
this question has been removed.
refer to Question 4 in the instructions.
you must answer ‘no’ at questions
5
are you an australian resident for tax purposes?
Yes
No
6 and 9 (unless you are entitled
to a zone or overseas forces tax
offset). you must also answer ‘no’
at question 10.
6
are you claiming, or do you want to claim
you must answer ‘no’ at
Yes
No
questions 8, 9 and 10.
the tax‑free threshold from this payer?
7
(a) do you have an accumulated higher
Yes
No
education loan programme (help) debt?
(b) do you have an accumulated financial
Yes
No
supplement debt?
8
do you want to receive or vary family tax benefit
you must answer ‘no’ if you
Yes
No
(or your spouse) are receiving
by reducing the amount withheld from payments
fortnightly payments from the
made to you?
insert the estimated family
Family assistance office.
tax benefit amount you have
calculated using the family
tax benefit worksheet.
$
,
9
do you want to claim or vary your dependent
Yes
No
spouse, zone, overseas forces or special tax
insert your estimated total
offset by reducing the amount withheld from
tax offset amount from
payments made to you?
$
,
table J on page 15.
10 do you want to claim the senior australians tax
Yes
No
offset by reducing the amount withheld from
are you:
payments made to you?
a member of an
a member
single
illness-separated couple
of a couple
In‑ConfIdenCe – when completed
nat 3093-06.2007
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