Fields on page 9
No
Yes
No
Yes
When did you last deal with us
Details (for example, tax return)
Yes
No
Family name at that time
First given name
Other given names
Postal address for tax matters at that time
Suburb/town/locality
State/territory
Postcode
Country if outside Australia
Name of your registered tax agent at that time (if applicable)
Fields on page 10
Title: Mr
Mrs
Miss
Ms
Other
Family name
First given name
Other given names
No
Yes
Your previous married name
The name on your birth certificate
An anglicised name
Your name before marriage
A shortened version of your name
An assumed name (known as)
Your skin name
Other
Other
Title: Mr
Mrs
Miss
Ms
Other
Family name
First given name
Other given names
What is your gender? Male
Female
Indeterminate
What is your date of birth
What is your date of birth
Year
No
Yes
Spouse’s family name
Spouse’s first given name
Spouse’s other given names
Spouse’s date of birth
Spouse’s date of birth
Year
Fields on page 11
What is your postal address? (Your TFN will be sent to this address.) For example, write your home address, your post office box, or your Australian representative’s postal address.
Suburb/town/locality
State/territory
Postcode
Country if outside Australia
What is your home address outside Australia? This must be a street address.
Suburb/town/locality
Country
Q11
Street address of rental property
Suburb/town/locality
State/territory
Postcode
Real estate agent’s name
Real estate agent’s address
Suburb/town/locality
State/territory
Postcode
Q11
If applicable, provide a business or company name
Australian Registered Body Number (ARBN) or Australian Company Number (ACN)
Fields on page 12
Q11
Provide the details of the entity that pays you. Name of company, partnership, trust or individual
Street address
Suburb/town/locality
State/territory
Postcode
Australian Company Number (ACN) – if a
Australian business number (ABN)
Q11
Name of trust
Trust ABN
Q11
n make personal contributions into an Australian fund, or n are having contributions made on your behalf into an Australian fund. Name of fund
Fund ABN
Q11
Give full details, including any associated ACN or ABN.
Q11
Q11
No
Yes
Provide your Centrelink Customer Reference Number (CRN)
Q11
Fields on page 13
Provide all details where you can. We may use these details to your taxation affairs. Daytime phone number (include area or country code)
Mobile number (include country code)
Email address (use BLOCK LETTERS) – such as EXAMPLE@PROVIDER.COM.AU
No
Yes
Title: Mr
Mrs
Miss
Ms
Other
Family name
First given name
Other given names
Daytime phone number (include area or country code)
Mobile number (include country code)
Email address (use BLOCK LETTERS) – such as EXAMPLE@PROVIDER.COM.AU
No
Yes
Name of practice
Phone number (include area code)
Name of person you deal with
Registration number
Fields on page 14
Primary
15-Qb
15-Qc
15-Qd
Secondary
15-Qf
15-Qg
it will not
No
Yes
16-Qa
16-Qb
EITHER of the
Your own tax file number (TFN)
OR
No
Yes
No
Yes
Fields on page 15
The person applying for the TFN
A parent or guardian
Make sure you have completed questions 13 and 16, then provide your full name here A parent or guardian before signing and dating the declaration below. Name of parent or guardian
Date Day
Month
Year
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