FAIR WORK REGULATIONS 2009 - SCHEDULE 4.1 Form of claim for unclaimed money
FAIR WORK REGULATIONS 2009 - SCHEDULE 4.1
Form of claim for unclaimed money(regulation 4.11)
Fair Work Regulations 2009 , regulation 4.11
CLAIM FOR UNCLAIMED MONEY
Claimant's Details
Claimant's name | |
Residential address | |
| Postcode |
Postal address (if different from above): | |
| Postcode |
Daytime phone no. ( ) Mobile no. (if any): | |
Email address (if any): | |
Details of the Claim
Please provide the following details regarding your former employment and the amount the employer was required to pay to you.
Name of former employer |
Address of former employer |
Date of commencing former employment |
Date of leaving former employment |
Amount claimed |
Please attach evidence showing that you were employed by the former employer (for example, a pay slip).
Please provide any further information about the circumstances of your claim that you would like to be considered.
|
|
|
|
|
|
Payment Details
Please indicate how you would like to be paid the unclaimed money (mark the appropriate box).
□ direct debit to a particular account; or
□ a cheque posted to the residential or postal address you provided in this form
If you have selected direct debit, please provide the following:
Account name (eg. Jan and John Citizen) | |||||||||
Name of financial institution | Branch: | ||||||||
BSB number |
|
|
| − |
|
|
| ||
Account number |
|
|
|
|
|
|
|
|
|
Declaration/Authority
I declare that
ï‚· the information provided in this claim form is true and correct to the best of my knowledge.
ï‚· I understand that making a false declaration is an offence.
I authorise and direct the Fair Work Ombudsman to pay the money claimed, and any additional money the Fair Work Ombudsman may identify as belonging to me, in the way I have directed in this form (by direct deposit or cheque).
Claimant's name: | |
Claimant's signature: | Date / / |