Form of claim for unclaimed money
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
• the information provided in this claim form is true and correct to the best of my knowledge.
• 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 / / |
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