Mail To:

In House Benefit Form - FBT Exempt item

(Combined annual threshold of $1,333.33 applies)

Smartsalary Pty Ltd QLD-GOVT Applications GPO Box 4244 Sydney NSW 2001 1300 708 144

Fax:

The Queensland Government strongly recommends that Financial Advice is obtained prior to entering into a Salary Packaging Agreement. You are entitled to Salary Package electricity at your place of residence and/or public transport costs incurred by you or your family for public transport provided by Brisbane City Council or Queensland Rail. You can salary package either electricity or public transport or a combination of both as a fringe benefits tax (FBT) exempt benefit up to a combined limit of $1,333.33 per FBT year (1 April - 31 March). Please remember to sign the form before sending it to Smartsalary for processing.

Section A - Your Personal Details

Employer Given Name(s) Contact Number Smartsalary Account Number Log in to your online Smartsalary account at www.smartsalary.com.au to find your account number Payroll Number Surname

Please note: You can Salary Package this benefit item if you are an Employee of the Queensland Government entities listed below. Please select the unit/department you belong to:

Anti Discrimination Commission Commission for Children & Young People and Child Guardian CITEC Corporate Administration Agency CorpTech Dept of Communities Dept of Community Safety (inc EMQ, QAS, QF&R, Qld Rescue, & Corrective Services) Dept of Education and Training Dept of Employment, Economic Development and Innovation Dept of Environment and Resource Management Queensland Health Depr of Local Government and Planning Dept of Justice & Attorney General (incl Electoral Commission Qld & Industrial Registrar's Office) Dept of Premier & Cabinet (incl CAA, Arts Qld, Qld Museum, Qld Art Gallery and State Library) Dept of Public Works (incl all business units) Dept of Transport and Main Roads Energy Ombudsman Queensland TransLink Transit Authority Employing Office

GoPrint Magistrates Office Ministerial Services Branch Office of the Governor Office of the Information Commissioner Office of the Ombudsman The Public Services Commission Parliamentary Services Commission QBuild QFleet Queensland Audit Office Queensland Ombudsman's Office Queensland Police Service Queensland Treasury Queensland Water Commission Sales & Distribution Services (SDS) Shared Service Agency Residential Tenancies Employing Office (electricity only)
Version Date: 03-Aug-2011

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Smartsalary Pty Ltd ACN 096 796 100 GPO Box 4244, Sydney NSW 2001 Tel: 1300 218 598 Fax: 1300 708 144 Email: qld@smartsalary.com.au

Mail To:

In House Benefit Form - FBT Exempt item

(Combined annual threshold of $1,333.33 applies)
Section B - Reimbursement Details
Total Amount (including GST)

Smartsalary Pty Ltd QLD-GOVT Applications GPO Box 4244 Sydney NSW 2001 1300 708 144

Fax:

GST Amount

I have attached a copy of my tax invoice to substantiate this claim Smartsalary will make equal deductions and reimbursements over the number of pay periods that you nominate. Please select the number of pay periods you would like deductions and reimbursements to occur over (1 - 26) If your personal bank account details have changed since you applied for packaging please complete a "Change of Bank Account Details Form" to update your details.

Section C - Required Documentation

Expense type Public transport expenses Requirements for Supporting Documentation A copy of GoCard internet statement. Note: GoCard top up receipts will not be accepted to substantiate claims. A copy of all sides of valid tax invoice and proof of payment.

Electricity expenses

Please note: A maximum of four (4) claims per FBT year for electricity and/or public transport are included in your Salary Packaging administration fee for In House Benefits.

Section D - Employee Declaration

I hereby declare that: * The information provided is true and correct to my knowledge; * I have read and understand the the Salary Packaging Information Booklet and the In House Benefit Fact Form available on the Smartsalary website; * The attached invoice/s and/or receipt/s are for expenses incurred by me and have not and will not be claimed by me for any other tax deductible purpose and are budgeted for within my Salary Packaging Agreement; * I have read and accept the Smartsalary Terms & Conditions available on the Smartsalary website; and * I authorise Smartsalary to alter my deductions in accordance with the requirements of my salary package. Direct Debit Request Declaration * I acknowledge that upon cessation of my salary package, any amounts owed by me in relation to my salary packaging that have not been collected from my pay must be paid directly by me. I request Smartsalary (User ID 373142) to direct debit the bank account held by Smartsalary as my Personal Bank Account for these amounts owing. * I have read and understand the Direct Debit Service Agreement available on the Smartsalary website.

Signature:
IMPORTANT: This section must be signed otherwise your claim will not be processed.

Date

Print Form

Privacy Notice: Smartsalary is collecting your personal information on this form for the purpose of processing your salary packaging agreements. Smartsalary will pass your personal information on to your Agency's payroll section as part of the administration of your salary packaging agreements, the Queensland Government Chief Procurement Office in relation to the management of the Salary Packaging Arrangement and Queensland Treasury for auditing purposes. Your personal information will not be used for any other purpose or disclosed to any other third party, without your consent, unless authorised or required by law.
Version Date: 03-Aug-2011

Page 2 of 3

Smartsalary Pty Ltd ACN 096 796 100 GPO Box 4244, Sydney NSW 2001 Tel: 1300 218 598 Fax: 1300 708 144 Email: qld@smartsalary.com.au

Mail To:

Electricity and Public Transport In-house Benefits Declaration

Section A - Your Personal Details
Employer Given Name(s) Contact Number Smartsalary Account Number (if currently packaging) Surname

Smartsalary Pty Ltd QLD-GOVT Applications GPO Box 4244 Sydney NSW 2001 1300 708 144

Fax:

Payroll Number

Log in to your online Smartsalary account at www.smartsalary.com.au to find your account number

Section B - Employee Declaration

I hereby advise that: (a) I am claiming a reimbursement for the costs of electricity services provided by a Queensland Government generator and/or public transport services supplied by Queensland Rail and/or Brisbane City Council buses and ferries only. (b) The attached invoice/s, receipt/s or GoCard history statements are for expenses incurred privately by myself or by a family associate and are budgeted for within my salary packaging agreement. (c) If I am claiming reimbursement for electricity: 1. The attached electricity invoice/s are in the name of: the claimant spouse Defacto Partner (living with the claimant) relative living with the claimant

2. I declare that the attached invoice/s are for electricity consumed in: my current primary place of residence (d) If I am using a GoCard then: 1. I have used, and will continue to use, the GoCard for the costs of public transport services supplied to me or a family associate by Queensland Rail and/or Brisbane City Council bus and ferry only; 2. There have not been any redraws of credit from the GoCard for the period to which the claim for reimbursement relates; OR Amounts totalling $............................. have been withdrawn from the GoCard for the period to which the claim for reimbursement relates and my claim for reimbursement does not include the amount that has been withdrawn; 3. On request by the Employer, I will provide to the Employer and/or Smartsalary all records, receipts, documents accounts and supporting information reasonably required by the Employer to enable the Employer to determine whether the GoCard has been used solely for Queensland Rail and/or Brisbane City Council bus and ferry travel; and (e) I acknowledge that I am liable for all costs, losses, outgoings and liabilities, including, without limitation, any penalties, or general interest charge payable under any taxation legislation suffered or incurred by the Employer, arising out of my failure to comply with the preceding paragraph, in accordance with the terms and conditions of my salary packaging participation agreement. or a previous primary place of residence

Signature:
IMPORTANT: This section must be signed otherwise your claim will not be processed.

Date

Print Form
Privacy Notice: Smartsalary is collecting your personal information on this form for the purpose of processing your salary packaging agreements. Smartsalary will pass your personal information on to your Agency's payroll section as part of the administration of your salary packaging agreements, the Queensland Government Chief Procurement Office in relation to the management of the Salary Packaging Arrangement and Queensland Treasury for auditing purposes. Your personal information will not be used for any other purpose or disclosed to any other third party, without your consent, unless authorised or required by law.
Version Date: 03-Aug-2011

Page 3 of 3

Smartsalary Pty Ltd ACN 096 796 100 GPO Box 4244, Sydney NSW 2001 Tel: 1300 218 598 Fax: 1300 708 144 Email: qld@smartsalary.com.au