Alcohol Ignition Interlock Program - Financial Assistance Scheme Application - Queensland Department Of Transport And Main Roads Page 3
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4Alcohol Ignition Interlock Program - Financial Assistance Scheme Application ... continued page 3 of 4
Part C: Financial declaration
(to be completed by the
(b) Please provide details of the income earned from your
involvement in the business
applicant and their partner if applicable, or the applicant’s parent/
guardian and their partner if applicable)
$
per annum
A separate financial declaration is required for each applicable
Please note: you will need to provide a witnessed copy of your
person (applicant/applicant’s partner/applicant’s parent or
most recent taxation return and business financial statements.
guardian/ applicant’s parent or guardian’s partner – please print
4. Income stream product details
additional pages as required.
An income stream product is a regular series of payments which may be
Name of person completing the financial declaration
made for a lifetime or a fixed period including, allocated pension/
annuity, superannuation pension, market-lined pension/annuity.
(a) Are you receiving income from an income stream product?
I am the:
No
Go to 5
applicant
Yes
Income stream product type
applicant’s partner
applicant’s parent/guardian (on whom the applicant is dependent)
(b) Please provide details of the income earned
applicant’s parent/guardian’s partner
$
per annum
Please note: you will need to provide a witnessed copy of your
1. Employment income details
most recent taxation return and financial statements for this
income source.
(a) Are you currently employed?
If you received income from more than one income stream product
(Do not include self-employment – refer to section 3)
attach a separate sheet with details.
No
Go to 2
5. Compensation, insurance or damages payment details
Yes
Employer’s name
Income from compensation, insurance or damages includes workers’
compensation, sporting injury compensation, public liability compensation,
medical negligence compensation, personal accident and sickness
Address
insurance, income protection insurance, third party damages as a result of
a vehicle accident, damages paid to victims of crime or as a result of
criminal injuries.
(a) Are you receiving payments from compensation, insurance or
Postcode
damages claims?
Phone number
No
Go to 6
Yes
Payment type
If you received income from more than one employer attach a
separate sheet with details.
(b) Please provide details of the income earned (after tax) from your
(b) Please provide details of the payment received
employment in the past eight weeks
$
per annum
$
Week 1
$
Week 5
Please note: you will need to provide a witnessed copy of your
$
Week 2
$
Week 6
most recent taxation return and financial statements for this
payment.
$
Week 3
$
Week 7
If you received payments from more than one source attach a
separate sheet with details.
$
Week 4
$
Week 8
6. Other income details
Please note: you will need to provide witnessed copies of
Other income includes income received from shares, managed investments,
payslips for the past eight weeks to verify your income.
trusts, interest, rental properties.
2. Centrelink payment details
(a) Are you receiving income from any source not previously
(a) Are you receiving income payments from Centrelink?
identified in this declaration?
No
Go to 3
No
Go to 7
Yes
Payment type
Yes
Source of income
(b) Please provide details of the payment received (after tax) from
(b) Please provide details of the income earned
Centrelink in the past eight weeks, excluding payments for rent
$
per annum
assistance
Please note: you will need to provide a witnessed copy of your
$
Week 1
$
Week 5
most recent taxation return and financial statements for this
income source.
$
Week 2
$
Week 6
If you received income from more than one source attach a separate
$
Week 3
$
Week 7
sheet with details.
$
Week 4
$
Week 8
Please note: you will need to provide witnessed copies of
your income statements for the past eight weeks to verify your
income.
3. Business income details
(a) Are you involved in any type of business?
(include farming, self-employed, sole trader, partnership, sub-contractor)
No
Go to 4
Yes
Business type
continued page 4...
Page 3 of 4 SSA Multimedia Services Form F4899 ES V01 Apr 2011
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