Fields on page 5
Your Centrelink
Reference Number (if
Number (if known)
known)
Family name
First given name
Second given name
Your date of birth
No
the definition of a
Yes
Family name
First given name
Second given name
Your partner’s date of birth
No
you have
Yes
No
Yes
No
No
You will need to wages from this
Yes
Fields on page 6
This private company will be referred to as ‘the company’ on the rest of this form.
Company tax file
tax file number
number (Company TFN)
Company
Australian Business
Business Number
Number (Company ABN)
Company Australian
Australian Company
Company Number
Name
Business name (if applicable)
Position in relation to the company discussed in this form
Postal address
Postal address
Q12.PostalAddress3
Postcode
Daytime phone number
Fax number (
)
The person named at question 12
The person named below
Name
Name
Business name (if applicable)
Position in relation to the company discussed in this form
Postal address
Postal address
Q13Details.PostalAddress3
Postcode
Daytime phone number
Fax number (
)
In which month are the taxation returns statements for the company normally
No
Yes
Give details below
Name of the trust
When was the company incorporated
What date did the company commence
No
Yes
No
Fields on page 7
What date did the company cease
Explain why the company ceased trading
Trading name
Type of business (for example, primary production, retail, commercial, investment)
Trading name
Type of business (for example, primary production, retail, commercial, investment)
Trading name
Type of business (for example, primary production, retail, commercial, investment)
No
• a
Yes
Trading name of business
You
Your partner
Trading name of business
You
Your partner
Trading name of business
You
Your partner
Fields on page 8
Details of directors 1 Name
Date of birth
Centrelink Reference
Reference Number (CRN) (if
(CRN) (if known)
known)
Permanent address
Permanent address
Q24.0.PermAddress3
Postcode
Name
Date of birth
Centrelink Reference
Reference Number (CRN) (if
(CRN) (if known)
known)
Permanent address
Permanent address
Q24.1.PermAddress3
Postcode
Name
Date of birth
Centrelink Reference
Reference Number (CRN) (if
(CRN) (if known)
known)
Permanent address
Permanent address
Q24.2.PermAddress3
Postcode
Class (for example, Ordinary, Class A, Class B) Number
B) Number
Voting rights provided
Entitlement to dividends
Entitlement to capital distributions on wind up
Class (for example, Ordinary, Class A, Class B) Number
B) Number
Voting rights provided
Entitlement to dividends
Entitlement to capital distributions on wind up
Class (for example, Ordinary, Class A, Class B) Number
B) Number
Voting rights provided
Entitlement to dividends
Entitlement to capital distributions on wind up
Class (for example, Ordinary, Class A, Class B) Number
B) Number
Voting rights provided
Entitlement to dividends
Entitlement to capital distributions on wind up
Class (for example, Ordinary, Class A, Class B) Number
B) Number
Voting rights provided
Entitlement to dividends
Entitlement to capital distributions on wind up
Fields on page 9
Class (for example, Ordinary, Class A, Class B) Number
B) Number
Voting rights provided
Entitlement to dividends
Entitlement to capital distributions on wind up
Name
Date of birth
CRN (if known)
Tick if related to: Director(s)
Other shareholders
Other office-holders
for this shareholder
for this shareholder
$
Date purchased shares
/
Number
$
Date purchased shares
Name
Date of birth
CRN (if known)
Tick if related to: Director(s)
Other shareholders
Other office-holders
for this shareholder
for this shareholder
$
Date purchased shares
/
Number
$
Date purchased shares
Name
Date of birth
CRN (if known)
Tick if related to: Director(s)
Other shareholders
Other office-holders
for this shareholder
for this shareholder
$
Date purchased shares
/
Number
$
Date purchased shares
Fields on page 10
Name
Date of birth
CRN (if known)
Tick if related to: Director(s)
Other shareholders
Other office-holders
for this shareholder
for this shareholder
$
Date purchased shares
/
Number
$
Date purchased shares
Name
Date of birth
CRN (if known)
Tick if related to: Director(s)
Other shareholders
Other office-holders
for this shareholder
for this shareholder
$
Date purchased shares
/
Number
$
Date purchased shares
Name
Date of birth
CRN (if known)
Tick if related to: Director(s)
Other shareholders
Other office-holders
for this shareholder
for this shareholder
$
Date purchased shares
/
Number
$
Date purchased shares
Name
Date of birth
CRN (if known)
Tick if related to: Director(s)
Other shareholders
Other office-holders
for this shareholder
for this shareholder
$
Date purchased shares
/
Number
$
Date purchased shares
Fields on page 11
No
Yes
Yes
Yes
No
Yes
Give details below
Date change occurred
Change in circumstances since last financial statement
No
Yes
Give details of each contribution
Name of contributor
Date of birth
Still living
Deceased
Nature of the contribution: Gifted
Transferred
Sold for less than market value
What was contributed
Date of contribution
$
$
Fields on page 12
No
Yes
Give details below
Name of the public company or ASX code
Number of shares held
Name of the public company or ASX code
Number of shares held
Name of the public company or ASX code
Number of shares held
Name of the public company or ASX code
Number of shares held
Name of the public company or ASX code
Number of shares held
Name of the public company or ASX code
Number of shares held
No
Yes
Give details below
Name of the fund manager
Name of the product and product option
Number of units held (if applicable)
APIR code (if known)
$
Name of the fund manager
Name of the product and product option
Number of units held (if applicable)
APIR code (if known)
$
Name of the fund manager
Name of the product and product option
Number of units held (if applicable)
APIR code (if known)
$
Fields on page 13
Name of the fund manager
Name of the product and product option
Number of units held (if applicable)
APIR code (if known)
$
Name of the fund manager
Name of the product and product option
Number of units held (if applicable)
APIR code (if known)
$
Name of the fund manager
Name of the product and product option
Number of units held (if applicable)
APIR code (if known)
$
No
Yes
Give details below
Name of the company
Company ABN or ACN
Name of the company
Company ABN or ACN
Name of the company
Company ABN or ACN
Name of the company
Company ABN or ACN
Name of the company
Company ABN or ACN
Name of the company
Company ABN or ACN
Fields on page 14
No
Yes
Give details of each trust
Name of the private trust
Name of the private trust
the private trust
Q33Details.0.TFN3
Q33Details.0.ABN1
Q33Details.0.ABN2
Q33Details.0.ABN3
Q33Details.0.ABN4
Name of the private trust
Name of the private trust
the private trust
Q33Details.1.TFN3
Q33Details.1.ABN1
Q33Details.1.ABN2
Q33Details.1.ABN3
Q33Details.1.ABN4
Name of the private trust
Name of the private trust
the private trust
Q33Details.2.TFN3
Q33Details.2.ABN1
Q33Details.2.ABN2
Q33Details.2.ABN3
Q33Details.2.ABN4
Name of the private trust
Name of the private trust
the private trust
Q33Details.3.TFN3
Q33Details.3.ABN1
Q33Details.3.ABN2
Q33Details.3.ABN3
Q33Details.3.ABN4
No
Does the
Yes
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Other (describe)
$
$
Other (describe)
$
$
Q35Details.AssetDes3
$
$
Fields on page 15
No
more information about
Yes
Name of person or associate
Date of birth
$
Interest rate paid on the loan
Name of person or associate
Date of birth
$
owed
Name of person or associate
Date of birth
$
Interest rate paid on the loan
No
Yes
No
Yes
Give details for each liability
Type of liability
$
Asset secured against
$
Tick if this is collateral security
Tick if this is a primary production asset
Type of liability
$
Asset secured against
$
Tick if this is collateral security
Tick if this is a primary production asset
Type of liability
$
Asset secured against
$
Tick if this is collateral security
Tick if this is a primary production asset
Fields on page 16
No
superannuation
Yes
Name
Date of birth
$
$
$
$
Other income type (for example, director’s fees, bonus shares)
$
Financial year of payment
No
Yes
Name
Date of birth
$
$
$
$
Other income type (for example, director’s fees, bonus shares)
$
Financial year of payment
No
Yes
No
Yes
Give details below
Date change occurred
Details of current income
No
Yes
Give details of each director or shareholder
Name
Date of birth
/
$
Financial year of payment
Name
Date of birth
/
$
Financial year of payment
Name
Date of birth
/
$
Financial year of payment
Fields on page 17
No
the company own any
Yes
How many properties
Fields on page 18
Name of the company which owns the real estate
Company ABN
ABN
Q43.ABN3
Q43.ABN4
Address of the property
Address of the property
Q44.PropertyAddress3
Q44.PropertyAddress4
Postcode
Country (if not in Australia)
What date did the property become an
Vacant land
Bush block
Home office/business
House
Self contained flat (part of or
Units/flats/town house
Retail premises
Commercial premises
Industrial premises
Farm (or hobby farm)
Market garden
Residential block larger than
Other
Other
Other
If the property is made up of more than 1 title, give details for each separate title.
$
No
Is there a
Yes
No
Does any
Yes
No
Is the
Yes
$
No
Does the
Yes
Fields on page 19
$
Provide the legal description and area of the title on which the residence sits.
No
•
Yes
No
more
Yes
No
Yes
themselves
Yes themselves
No
Yes
Describe the potential commercial use
Yes
No
Yes
No
No
there any reason that
Yes
Rural residential block
Land is not viable for commercial
Caring responsibilities
Health reasons
Zoning restrictions
Environmental restrictions
Other
Other
Other
Do not currently make any use of
Primary production
Rural residential only
Leased
Other commercial or business
Hobby farm
Other
Hobby farm
Other
No
Yes
Fields on page 20
No
Yes
No
Name of person/entity
Percentage owned
Name of person/entity
%
Q65.2.Name
%
Area in hectares
Area in acres
Area in square metres
Dimensions
X
What is the approximate floor How old is area in square metres
How old is the building
Exterior (for example, brick, timber)
Interior (for example, plaster, not lined)
Roof (for example, metal, tiles)
General condition (for example, good, fair, poor)
good, fair, poor)
in the
of
What is the approximate floor How old is area in square metres
How old is the building
Exterior (for example, brick, timber)
Interior (for example, plaster, not lined)
Roof (for example, metal, tiles)
General condition (for example, good, fair, poor)
good, fair, poor)
in the
of
Fields on page 21
No
Yes
Give details below
Date of loan
Interest rate
$
$
Name of finance provider
No
Yes
Give details below
Describe the asset or give the address of the property used to secure the loan.
$
No
Yes
Give details below
$
No
Yes
Give details below
Yes
If the property is hard to locate, give full directions or provide a map.
Fields on page 22
Name of authorised officer
Authorised officer’s signature
Date
Person to be contacted by the valuer
Their daytime phone number
Fields on page 23
Details of your wages from this company
(if you answered
Personal Income Tax Return for you
Personal Income Tax Return for your partner if they
Latest Income Tax Return for the company
Profit and Loss Statement for the company
Depreciation Schedule for the company
Balance sheet for the company
Notes to and forming part of the accounts
Trading account details for the company
Profit and Loss Statement(s) for all income sources
Additional Profit and Loss Statement(s) because the
If you are not able to lodge any of the required
If you are not able to lodge any of the required documentation, give an explanation below
Private Trust (Mod PT) form
A copy of the evidence of change in circumstances
A copy of the latest statement detailing the share
A copy of a document which gives details for each
Private Company (Mod PC) form
Copies of any written agreements concerning loans
A completed ‘Company real estate details’ section
A copy of the council rate/valuation notice for each
A copy of the water rights, allocation or licence
A copy of each title deed
The mortgage or loan agreement(s) showing which
Fields on page 24
76
Your signature
Date
Your partner’s signature
Date
