application for release · 2018. 5. 22. · nat 15080-12.2014 sensitive when completed page 1...

Sensitive (when completed)NAT 15080-12.2014

Application for release

Use this form to apply for release from your tax debts.

nRead Application for release from your tax debt (QC 27193) before you start this form.

nWrite clearly, using a black pen only.

nPlace X in all relevant boxes.

n If a question does not apply to you, write ‘N/A‘ (not applicable).

n If there is not enough space to provide full details, write the additional information on a separate page. Ensure that any additional pages are numbered and include the question number and your name or tax file number (TFN).

nDo not use pins or staples to attach other documents as they won’t pass through our scanning equipment (simply include them with the form).

n If you make a mistake ensure the correction is clear.

If you have not lodged all your income tax returns and activity statements, or are disputing an assessment, your application may not be considered.

If you have any questions about this form or you need help completing it, phone the Debt Hardship Team on 1300 788 347.

Section A: Your details1 Full name

Family name

First given name Other given names

Title: Mrs Miss Ms OtherMr

Day Month Year

2 Date of birth

It is not an offence not to provide your TFN but not doing so may delay this application. The ATO is authorised by the Taxation Administration Act to ask for information in this form.

3 Taxfilenumber(TFN)

4 Postal address

Suburb/town State/territory Postcode

Street number and name

Do you want this address recorded for all your accounts with the ATO? YesNo

5 Home address


Street number and name

Do you want this address recorded for all your accounts with the ATO? YesNo

If your home address is the same as your postal address, write ‘as above’

https://www.ato.gov.au/General/Managing-your-tax-debt/In-detail/Overview/What-happens-if-you-can-t-pay-your-tax-debt/Release-from-your-tax-debt/

Sensitive (when completed)

9 Do you, or a family member, have a medical condition or illness that you think we should take into account?

Provide detailsYes

No Go to question 10

6 Contact numbersIf we need more information, it is quicker for us to contact you by phone. What is your best direct contact phone number during business hours?

Phone number (including area code)

Mobile number

Email address

With emails there is a risk that your personal information may be obtained by others because the transmission is along a public medium. We will only use email as a back-up point of contact if we can’t contact you by other means. We will not include confidential information.

7 Are you currently employed?

Go to question 8No

Yes What is your employment status?

Salary/wage earner Name of employer

Self-employed Occupation

Self-funded retiree Income source

Government benefits Specify type

Income protection Source

Other Specify

8 Are you unemployed?

Day Month YearGo to question 9No

Yes Date you became unemployed


Section B: Your spouse or partner and family details

10e Is your spouse or partner also applying for release from his or her individual tax debt?

You can use this form to apply for release for you both. However, you both must sign the declaration on page 13.

Go to question 11

Yes

No

Day Month Year

10b Spouse or partner’s date of birth

10a Spouse or partner’s name

Family name

First given name Other given names

Title: Mrs Miss Ms OtherMr

10c Is your spouse or partner currently employed? (that is, are they a salary/wage earner having tax withheld by their employer?)

Go to question 10dNo

Yes What is your spouse/partner’s employment status?

Salary/wage earner Name of employer

Self-employed Occupation

Self-funded retiree Income source

Government benefits Specify type

Income protection Source

Other Specify

10d Is your spouse or partner unemployed?

Day Month YearGo to question 10eNo

Yes Date they became unemployed

10 Do you have a spouse or partner living with you?

Go to question 11No

Yes Provide details at questions 10a-10f

10f Spouse or partner’s tax file number(TFN), if they are also applying for release

It is not an offence not to provide your TFN but not doing so may delay this application. The ATO is authorised by the Taxation Administration Act to ask for information in this form.


13 BrieflydescribeyourcurrentaccommodationFor example, ‘I live in a rented, 20-year old, three-bedroom, single-level house in a city suburb’.

Full name Date of birth Relationship to you Amount of support (per fortnight)

$$$$

12 Listanychildren(oranyoneelse)not living with you,forwhomyoualsoprovidesomefinancial support

Full name of dependant(s) Date of birth Relationship to you Dependant’s fortnightly income

$$$$

11 Listallyourdependants(orotherpersons)living with youwhorelyonyouforfinancialsupport

16 Do you expect to have a tax bill in the future?

Provide details of how you will pay any future tax liabilitiesYes


15 Have you tried to obtain a loan to pay the debt?

Provide details belowYes


Section C: Your tax liabilities If there is not enough space to provide full details, write the additional information on a separate page. Ensure that

any additional pages are numbered and include the question number and your name or tax file number (TFN).

14 How did your tax debt arise, and what were the reasons for non-payment?


Section D: Income and expenditure detailsPART1:INCOME

17 Fortnightlyhouseholdincome(beforetax)Applicant

Salary or wages, including salary sacrificing and fringe benefits amounts

.00$ , .00$ ,

Commissions from sales .00$ , .00$ ,

Australian government pension, allowance or payment .00$ , .00$ ,

Family tax benefit .00$ , .00$ ,

Maintenance or child support you receive .00$ , .00$ ,

Business or partnership income (after expenses) .00$ , .00$ ,

Distributions (eg, partnership, family trust, deceased estate) .00$ , .00$ ,

Superannuation payments received .00$ , .00$ ,

Overseas government pension, allowance or payment .00$ , .00$ ,

Income from rental property .00$ , .00$ ,

Board and other contributions to household income .00$ , .00$ ,

Total before tax .00$ , .00$ ,

Spouse or partner (if applicable)

.00$ , .00$ ,Insurance income (eg, worker’s compensation, income protection insurance) (Attach details on a separate page if necessary)

.00$ , .00$ ,Other (eg, bonuses, directors fees, incentives) (Attach details on a separate page if necessary)

Dividends .00$ , .00$ ,

Interest .00$ , .00$ ,

Total after tax .00$ , .00$ ,


PART2:EXPENDITURESUMMARY(PERSONAL-HOUSEHOLDEXPENDITUREONLY)

18 Fortnightlypersonalhouseholdexpenses(donotincludebusinessexpenses)

Food and household expenses .00$ ,

Household repairs and maintenance .00$ ,

Electricity and gas .00$ ,

Telephone (including mobile phone) .00$ ,

Internet, pay television .00$ ,

Water, council rates .00$ ,

Clothing .00$ ,

Vehicle registration and insurance .00$ ,

Vehicle repairs and maintenance .00$ ,

Vehicle loan repayments or leasing charges .00$ ,

Fares .00$ ,

School fees and other educational expenses .00$ ,

Household insurance .00$ ,

Health insurance .00$ ,

Life insurance, sickness or accident insurance .00$ ,

Superannuation contributions (other than employer deductions) (eg, salary sacrifice) .00$ ,

Medical, dental and pharmacy .00$ ,

Maintenance or child support .00$ ,

Child care .00$ ,

Hire purchase payments .00$ ,

Loan repayments .00$ ,

Entertainment .00$ ,

.00$ ,Mortgage Rent Board

Total .00$ ,

.00$ ,Other (Attach details on a separate page if necessary)

Petrol and oil .00$ ,

Credit card repayments .00$ ,


Section E: Asset and investment detailsASSETSUMMARY

19f Have you borrowed against this property to obtain loans for other purposes?

Provide details Yes


Reason for refinance (for example, debt consolidation, renovation, holiday)

Date of refinanceDay Month Year

19 Do you or your spouse or partner own or are you buying the home you live in?

Provide details at questions 19a–fYes



19a Property address

19b Name of title holder(s)

Day Month Year

Date of purchase Purchase price

.00$ ,,

Current market value

.00$ ,,

19c Purchase details

Mortgage details

Name of loan provider

First mortgage Second mortgage

Term of loan

Date loan taken out

Amount of loan $ $Current balance $ $

19d Mortgage details If you have more than one mortgage, provide the following details for each mortgage.

Do you have the capacity and/or the ability to draw against the above mortgage(s)?

.00$ ,How much can you draw against the mortgage(s)?Yes

No Reason

.00$ ,What are the minimum payments PER FORTNIGHT you are required to make on the above mortgage(s)?

.00$ ,What payments PER FORTNIGHT are you currently making on the above mortgage(s)?

19e Repayments


20 Doyouoryourspouseorpartnerownamotorvehicle(includesmotorcycle),caravanorboat?

Provide detailsYes


Vehicle details Vehicle 1 Vehicle 2 Caravan Boat

Owner

Year and make (for example, 2006 Holden)

Model

Purchase date

Current market value $ $ $ $Amount owed $ $ $ $Date of loan

22 Haveyouoryourspouseorpartnerbeenabeneficiaryofadeceasedestatesinceyourtaxdebtarose?

Provide detailsYes


Day Month Year

Date received or expectedValue of distribution

.00$ ,,

Full name of deceased estate

21 Do you or your spouse or partner have any other assets not mentioned so far? (For example, antiques, jewellery, art works)

Provide a description of each asset and its current market value Yes


Description of asset Current market value

$$$$$


25 Do you have any current claims for compensation? (That is, worker’s compensation, motor or road accident compensation, insurance claims or court action for damages)

Provide details on a separate page. For example, name and address of insurer, amount of claim, claim number, name of legal representative, and date you expect to receive payment .

Ensure that any additional pages are numbered and include the question number and your name or tax file number (TFN).

Yes


INVESTMENTSUMMARY

24 Do you or your spouse or partner hold any shares in publicly listed companies, bonds or units in a unit trust?

Provide detailsYes


In whose name TypeNumber of shares or units Date purchased

Maturity date (bonds) Value

$$$$

23 Do you or your spouse or partner own or are you buying any property for investment purposes? (For example, residential or commercial properties for rent or lease)

Provide details at questions 23a-bYes



Address

Name of title holder(s)

Day Month Year

Date of purchase Purchase price

.00$ ,,

Current market value

.00$ ,,

23a Investment property details If you have more than one investment property, provide the following details for each property.

Mortgage details

Name of loan provider

First mortgage Second mortgage

Term of loan

Date loan taken out

Amount of loan $ $Current balance $ $

23b Mortgage details If you have more than one mortgage on the investment property or properties, provide the following details for each mortgage.


Section F: Bank accounts and credit or store cards

28 Does anyone owe money to you or your spouse or partner?

Provide details. If more than one person owes you money, provide the following details for each amount owed.Yes


Debtor’s nameAmount owed to you

$$

Reason Payment due date

26 Provideallfinancialdetailsrelatingtoyou,yourspouseorpartneranddependants.Includeanybankorcredit society accounts, investments, term deposits or money held in trust and all credit card debts.

Institution Account nameAccount type (eg, savings, term deposit) Account number Balance

$$$$

26a Savings

Institution Account nameCredit card or store card limit Balance owing

Minimum fortnightly payment

Actual fortnightly payment

$ $ $ $$ $ $ $$ $ $ $

$$$

$$$

$$$

$$$

26b Credit cards

27 Do you or your spouse or partner owe money to any other people or institutions not mentioned so far? (For example, finance companies or relatives)

Provide details at questions 27a–bYes


Lender Account nameAmount borrowed

$

$

Balance owing

$

$

Minimum fortnightly payments

$

$

Actual fortnightly payments

$

$

27a Personal loans/finance company loans

Lender Account nameAmount borrowed

$

$

Balance owing

$

$

Minimum fortnightly payments

$

$

Actual fortnightly payments

$

$

27b Private loans


Section G: Business

29 Have you or your spouse operated a business as a sole trader?

Provide details. If there is or has been more than one business, provide the following details for each business.Yes


Business name

Australian business number (ABN)Day Month Year

Business start dateDay Month Year

Business cease date

SOLETRADER

30 Have you or your spouse or partner operated a business in a partnership?

Provide details. If there is or has been more than one partnership, provide the following details for each partnership.Yes


Business name

Australian business number (ABN)Day Month Year

Business start dateDay Month Year

Business cease date

PARTNERSHIP

COMPANIES

31 Have you or your spouse or partner ever been a company director?

Provide details. If you are or have been a director of more than one company, provide the following details for each directorship.Yes


Company name

Company TFN

Directors names

TRUSTS

32 Do you or your spouse or partner have an interest in a trust?

Provide details. If you have or have had interests in more than one trust, provide the following details for each trust. Yes


Name of trust

Trust TFN

Principal activity of trust

Name of trustee

Names of beneficiaries of trust


Section H: Other

If there is not enough space to provide full details write the additional information on a separate page. Ensure that any additional pages are numbered and include the question number and your name or tax file number (TFN).

33 Are there any other factors that you believe are important and which have not yet been mentioned in this application? (For example, natural disasters affecting you, death or serious illness in the family, or divorce or marital breakdown)

Provide details Yes


ATO employee Tax agent ato.gov.au website Financial counsellor

34 Howdidyoufindoutaboutthisform?Tick one of the boxes below

Other Please specify

Now you need to print this application and complete in pen the declaration on the next page.


How to lodge your applicationSend your application to: Australian Taxation Office Reply Paid 3129 PENRITH NSW 2740

You do not need to put a postage stamp on the envelope.

Your tax affairsI/we have lodged all of my/our income tax returns and activity statements.

I/we do not have an unresolved dispute with the ATO (for example, you objected to an income tax assessment or requested an amendment to your assessment which has not yet been resolved).

Application checklist (tick all boxes once complete)

I/we have signed the declaration. (You must sign and date the declaration or your application will not be considered.)

I/we have kept a copy of the application for our records.

I/we have answered all questions. (including N/A for all questions that do do not apply to you)

If you have not complied with all the above conditions, your application may not be considered.

Section I: DeclarationBefore you sign this formPlease check that you have provided accurate and complete information.

PenaltiesYou should be aware that penalties may be imposed for giving false or misleading information.

PrivacyTaxation law authorises the ATO to collect information, including personal information about the person authorised to sign the declaration. We may disclose this information to other government agencies. For information about your privacy go to ato.gov.au/privacy

Your declaration I/we declare that the information given on this form is true and correct.

Signature

DateDay Month Year

Signature (spouse, if applicable)

DateDay Month Year

I authorise my spouse/partner to discuss my tax affairs with the ATO

YesNo

http://www.ato.gov.au/privacy

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