1

Benefit Claim Form salarypackaging@fleetplus.com.au

Your Personal Details

Given Name(s) Surname

Contact Phone Number Mobile No

Email Address

Your Email Address is used for communication of matters related to your Package only, and is kept confidential

Employer Name Gross Salary $

Employment Status

Full/Part Time Payroll Number

Fixed Term, Contract Ends: ____________________________

Pay Cycle Monthly Fortnightly Weekly

Reimbursement Details & Your Personal Bank Details

Benefit Type e.g. laptop Number of Deductions

Reimbursement amount inclusive of GST

$ Tax Invoice must be provided for substantiation purposes

Y N

Name of Account Holder

BSB Number (must be 6 digits)

Account Number

Note: The above amount will be reimbursed in the minimum number of pay deductions unless otherwise advised. Please note that there is an administration fee applicable.

Employee Declaration

I hereby declare that:

The information provided is true and correct to my knowledge;

I authorise FleetPlus to alter my deductions in accordance to the requirements of my salary package; and

I acknowledge that payments/or reimbursements can only occur after sufficient salary sacrifice has occurred for

that benefit item

I am responsible for all subsequent FBT liability associated with all benefit items I package howsoever caused plus

ATO interest, fees, charges, and penalties levied against any/all benefit item(s) packaged

Signature Date

1

Business Use Declaration salarypackaging@fleetplus.com.au

Your Personal Details

Given Name Surname

Employer Name

Employee Declaration

I, ____________________________________________________________ , declare that I have incurred

the costs on the substantiation attached primarily for work related purposes and the expenses were

required for the following purpose(s):__________________________________

______________________________________________________________________________

(Please give sufficient information to demonstrate the extent to which the expenses were incurred by you for the purposes of earning you assessable income)

I declare that the percentage of those expenses incurred in earning my assessable income was 100% or

_______% (please select)

I hereby declare that the information provided is true and correct

Employee Signature Date

Employer Declaration

I, ________________________________________________________ , an authorised signatory

for_______________________________ (insert company name), declare that the above expenses relate to

the employee’s duties as follows: _______________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I hereby declare that the information provided is true and correct

Employer Signature Date

2

Collection Statement for FleetPlus

FleetPlus Pty Limited and its wholly owned subsidiaries (“FleetPlus” or “we” “us” or “our”) collect your personal information (such as, but not limited to your name, address, employment history, bank account details, statement of assets and liabilities and income details).

This information will generally be provided by either you, your employer or a third party you have assisting you when you request that FleetPlus provides you with any of the following services:

Leasing

Salary Packaging

Fleet Management

We collect this personal and credit related information for the purposes of providing the requested product/services to you. We also collect this personal information for the purpose of sending you marketing communications about our products and/or services including via email and SMS. If we do not collect your personal and credit related information as described, we may not be able to provide you with the products or services you have requested.

We may disclose this personal and/or credit related information to entities including:

a bank;

your employer;

anyone you authorise us to disclose information to;

credit reporting agencies;

accountants, lawyers and other professional consultants;

suppliers, insurers, roadside assistance providers and repairers;

insolvency practitioners such as an administrators, receivers, liquidators or bankruptcy trustees;

motor vehicle registration authorities;

finance intermediaries; or

anyone to whom we are required to disclose the information by law

We may disclose this credit related information to the credit reporting body such as Veda Advantage. Veda Advantage may include the information in reports provided to FleetPlus to assist them to assess your credit worthiness. You may request Veda Advantage not to use such information for the purpose of pre-screening for direct marketing by FleetPlus and not to use or disclose such information if you believe on reasonable grounds that you are, or are likely to be, a victim of fraud. You can obtain a copy of Veda Advantage's credit reporting policy by visiting its website at www.mycreditfile.com.au.

Our privacy policy at http://www.fleetplus.com.au/privacy-policy and our credit reporting policy at http://www.fleetplus.com.au/privacy-policy contains information about:

how you may access the personal information that is held by us and seek correction of such information; and

how you may complain about a breach of the Australian Privacy Principles or Part IIIA of the Privacy Act 1988 (Cth) or a registered privacy code that binds us and how we will deal with such a complaint.

We may disclose your personal and/or credit related information overseas to our service providers in countries such as United States of America, Japan and Singapore.

You can contact us at treasury@fleetplus.com.au or by telephone at (02) 9911 3000 if you have any questions. You can obtain a copy of our privacy policy or credit reporting policy without charge on request.