CCI employer return exemption request

This form can be used by employers in the contract cleaning industry to apply for an exemption from completing a return for a worker who is currently, or was previously, engaged by the employer. We assess each of these applications individually to determine whether the exemption is granted.

Form CCI 9 v1

This form is issued in accordance with Section 64 of the Contract Cleaning Industry (Portable Long Service Leave) Act 2005.

Required fields are marked with an asterisk (*).

Employer details

Legal entity name *

ABN *

QLeave employer number *

Mailing address *

Suburb *

State

Postcode *

Worker details

How many workers are you requesting an exemption from lodging a return for? *

One worker
More than one worker

Name of worker *

QLeave worker number (if known)

Worker date of birth *

Worker email *

Worker phone *

Upload a spreadsheet with the details of your workers File must include worker's name, QLeave number (if known), date of birth, email and phone number

OR manually enter the details of your workers in the fields below Please contact us if you need to add more workers

Name of worker

QLeave worker number (if known)

Worker date of birth

Worker email

Worker phone

Name of worker #2

QLeave worker number (if known)

Worker date of birth

Worker email

Worker phone

Name of worker #3

QLeave worker number (if known)

Worker date of birth

Worker email

Worker phone

Name of worker #4

QLeave worker number (if known)

Worker date of birth

Worker email

Worker phone

Reason for exemption

Why are you requesting an exemption from lodging a return for the above worker/s? *

I no longer engage the person to perform cleaning work
My business complies with an interstate scheme

Please provide further details to support your request *

Please attach any supporting documents (optional)

Declaration

I certify that the information provided is true and correct, and that I am authorised to make this declaration for and on behalf of the employer. *

First name *

Last name *

Phone number *

Email *

Date *

CCI employer return exemption request

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Acknowledgement of Country