Tax file number declaration

This declaration is NOT an application for a tax file number.

■■ Use a black or blue pen and print clearly in BLOCK LETTERS.
■■ Print X in the appropriate boxes.
ato.gov.au ■■ Read all the instructions including the privacy statement before you complete this declaration.

Section A: To be completed by the PAYEE 5 What is your primary e-mail address?

1 What is your tax
file number (TFN)? 5 5 7 5 3 5 3 4 3 s h i l a s h r e s t h a 8 0 0
OR I have made a separate application/enquiry to
For more the ATO for a new or existing TFN. @ g m a i l . c o m
information, see
question 1 on page 2 OR I am claiming an exemption because I am under Day Month Year
of the instructions. 18 years of age and do not earn enough to pay tax.
6 What is your date of birth? 3 0 0 1 2 0 0 0
OR I am claiming an exemption because I am in
receipt of a pension, benefit or allowance. 7 On what basis are you paid? (select only one)
Full-time Part-time Labour Superannuation Casual
2 What is your name? Title: Mr Mrs Miss Ms employment employment hire or annuity employment ✘
income stream
Surname or family name
8 Are you: (select only one)
S H R E S T H A An Australian resident A foreign resident A working
First given name for tax purposes for tax purposes OR holiday maker
S H I L A 9 Do you want to claim the tax-free threshold from this payer?
Other given names Only claim the tax-free threshold from one payer at a time, unless your total income from
all sources for the financial year will be less than the tax-free threshold.
Answer no here if you are a foreign resident or working holiday
3 What is your home address in Australia? Yes No maker, except if you are a foreign resident in receipt of an
Australian Government pension or allowance.
8 / 2 4 B e l g r a v e S t r e e t 10 Do you have a Higher Education Loan Program (HELP), VET Student
Loan (VSL), Financial Supplement (FS), Student Start-up Loan (SSL) or
Trade Support Loan (TSL) debt?
Suburb/town/locality Your payer will withhold additional amounts to cover any compulsory
Yes repayment that may be raised on your notice of assessment. No ✘
K o g a r a h
State/territory Postcode DECLARATION by payee: I declare that the information I have given is true and correct.
Signature
2 1 3 4 Date
Day Month Year
4 If you have changed your name since you last dealt with the ATO,
provide your previous family name. You MUST SIGN here 2 7 0 4 2 0 2 5
There are penalties for deliberately making a false or misleading statement.

Once section A is completed and signed, give it to your payer to complete section B.

Section B: To be completed by the PAYER (if you are not lodging online)
1 What is your Australian business number (ABN) or Branch number 5 What is your primary e-mail address?
withholding payer number? (if applicable)

2 If you don’t have an ABN or withholding

payer number, have you applied for one? Yes No
6 Who is your contact person?
3 What is your legal name or registered business name
(or your individual name if not in business)?

Business phone number

7 If you no longer make payments to this payee, print X in this box.

DECLARATION by payer: I declare that the information I have given is true and correct.
Signature of payer
4 What is your business address? Date
Day Month Year

There are penalties for deliberately making a false or misleading statement.

Suburb/town/locality
Return the completed original ATO copy to: IMPORTANT
State/territory Postcode Australian Taxation Office See next page for:
PO Box 9004 ■■ payer obligations
PENRITH NSW 2740 ■■ lodging online.

Sensitive (when completed)

30920619
NAT 3092-06.2019 [DE-6078]