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Levy Refund Application
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How portable long service leave works
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Step 1 of 4 - Your Details
Title
*
-- Please Select --
Mr
Mrs
Ms
Miss
First Name
*
Last Name
*
Company Name
Phone
*
Email
*
Address
*
Suburb
*
State
*
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
*
Do you have a different mailing address?
Yes
No
Postal Address
Suburb
State
ACT
NSW
NT
QLD
SA
TAS
WA
VIC
Postcode
I certify that the information provided is true and correct to the best of my knowledge.
*
Yes
No
Contact Person
- Complete this if the contact person differs from the applicant
Contact Phone
- Complete this if the contact person has a different phone number to the applicant
Levy Payer Letter
- If you are not the original levy payer, please attach a letter from the levy payer approving this refund application
Step 2 of 4 - Building & Construction Work
Name of Principal Contractor
*
Name of owner
*
Building and construction work address
*
Suburb
*
State
*
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
*
Description of work
*
Notification and Payment form number
*
Completion date
Step 3 of 4 - Your Bank Details
Bank
Please provide your bank details to facilitate EFT payment.
BSB number
Account number
Account name
Step 4 of 4 - Reason for Refund Request
Why are you applying for a refund?
*
(Please select ONE option only)
Work did not commence and will not commence in the future
Cost of work is less than the original estimate by more than $20,000
Duplicate payment
Other
Letter confirming building/development application cancellation, OR documentation confirming no building/development application has been lodged *
- If a building/development application has been lodged, a copy of the letter received from council/certifier confirming the cancellation of your application (a Form 22 is not sufficient evidence)
- If a building/development application has NOT been lodged, a Statutory Declaration confirming that no building and construction work is to be carried out at the stated address on behalf of the owners at this time.
Original Estimate ($)
Enter whole numbers only
Actual Cost ($)
Enter whole numbers only
Difference in cost ($)
[Autofilled]
Please supply duplicate Notification and Payment form number
Documentation confirming cost of work *
(The following documentation must be uploaded or the refund may be delayed. At least one of: final progress certificate, amended contract, a relevant invoice,or the certificate of completion)
Describe the reason of the claim
- Please describe the reason of the claim
Relevant documentation *
- The following documentation must be attached or the refund may be delayed. Please attach copies, or provide Notification and Payment Form numbers in respect of duplicate payment
Relevant documentation *
- Upload any documents that will support your refund request
Submit
Date
*
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