Fields on page 1
Tax file number (TFN)
Signature
Date Day
Month
Year
Yes
No
Signature of spousepartner if applicable
Date Day
Month
Year
Fields on page 2
Date of birth Day
of birth Month
Year
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Other given names
Contact numbers What is your best direct phone number during Mobile number
during business Phone number
business hours? number (including area code)
Email address
Postal address Street number and name
Postal address Street number and name
Suburb/town
State/territory
Postcode
Yes
No
Home address (If your home address is the same as your postal address, write ‘as above’) Street number and name
Home address (If your home address is the same as your postal address, write ‘as above’) Street number and name
Suburb/town
State/territory
Postcode
Yes
No
Salary/wage earner
Salary/wage earner
Self-employed
Government benefits
Other
Self-employed
Government benefits
Other
Specify ‘other’ source
Yes
No
Yes
No
Fields on page 3
Yes
No
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Other given names
Date of birth
Month
Year
Are they also applying for release? No
Yes
Yes
Why didn’t you pay your tax by the due date
Why didn’t you pay your tax by the due date
3a-debt-Line3
What actions have you taken to try and pay off your debt
What actions have you taken to try and pay off your debt
3b-debt-Line3
If we release you from this debt, how do you plan to pay future tax bills
If we release you from this debt, how do you plan to pay future tax bills
3c-debt-Line3
List all persons living with you. Full name
Date of birth Relationship
birth Relationship to you income
$
$
Full name
Date of birth Relationship
$
$
$
4-name-3
4-dob-3
$
$
$
4-name-4
4-dob-4
$
$
$
List any other persons not living with you Full name
living with you that you provide Date of birth Relationship
that you provide financial support for. birth Relationship to you Amount of
$
Full name
Date of birth Relationship
$
$
Fields on page 4
Weekly
Fortnightly
Monthly
$
$
$
$
Business income (after expenses) $
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Other income (describe below)
Other income (describe below)
5-amount-Line3
$
$
$
$
Mortgage
Rent
Board
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
5-expenses-Line1
5-expenses-Line2
5-expenses-Line3
5-expenses-Line4
$ $
$
Fields on page 5
vehicles owned by you and your spouse or Vehicle 1
your spouse or partner. Vehicle 2
Vehicle 3
Vehicle 4
Year and make
Vehicle 2
Vehicle 3
Vehicle 4
Model
5-vehicle-model-2
5-vehicle-model-3
5-vehicle-model-4
Purchase date
5-vehicle-purchase date-2
5-vehicle-purchase date-3
5-vehicle-purchase date-4
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Yes
Provide details below. No
Property address Street number and name
Street number and name
Suburb/town
State/territory
Postcode
Name of title holder(s)
Name of title holder(s)
Date of purchase Day
of purchase Month
Year
$
$
Name of loan provider, eg bank
Second mortgage
First mortgage
Second mortgage
Date loan taken out
5-date-2
$
$
$
$
$
$
$
$
$
$
Yes
Provide details below. No
Date of refinance
Month
Year
Reason for refinance (for example, debt consolidation, renovation, holiday)
Reason for refinance (for example, debt consolidation, renovation, holiday)
Fields on page 6
Owners name
Description of asset
Purchased date Purchase
$
$
$
Owners name
Description of asset
$
$
$
$
5-OwnersName-3
5-asset-3
$
$
$
$
5-OwnersName-4
5-asset-4
$
$
$
$
5-OwnersName-5
5-asset-5
$
$
$
$
Institution
Account name
Account type
Account number
$
Institution
Account name
Account type
$
$
5-Institution-3
5-Account-name-3
5-Account-type-3
$
$
5-Institution-4
5-Account-name-4
5-Account-type-4
$
$
Institution
Credit card Account name
$
$
$
$
Institution
$
$
$
$
$
5c-Institution-3
$
$
$
$
$
5c-Institution-4
$
$
$
$
$
Account Lender
Account name
Date borrowed
$
$
$
$
Lender
Account name
$
$
$
$
$
5d-Lender-3
5d-Account-name-3
$
$
$
$
$
5d-Lender-4
5d-Account-name-4
$
$
$
$
$
Business name
Australian business number (ABN)
Business start date Day
start date Month
Year
Business cease Day
cease date Month
date Year
ato.gov.au website
Financial counsellor
ATO employee
Tax agent
Other
Please specify
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