Form 1—Notice to Centrelink of proposed Form 1—Notice to Centrelink of proposed dismissals

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## Form 1—Notice to Centrelink of proposed dismissals (regulation 3.30) Fair Work Act 2009, section 530 NOTICE TO CENTRELINK OF PROPOSED DISMISSALS TO: CENTRELINK I, \[full name of employer or person completing notice on behalf of employer\], the \[position held\] of \[name of employer of person completing notice\], give notice, under subsection 530(1) of the Fair Work Act 2009, that \[name of employer\] proposes to dismiss the employment of 15 or more of its employees, for the following reasons: \[Set out reasons for proposed dismissals. Reasons may be of an economic, technological, structural or similar nature, or for reasons including such reasons\] The number and categories of employees likely to be affected by the proposal are: \[Set out the categories and number per category\] It is intended that \[name of employer\] will carry out the proposed dismissals at the following time/s, or over the following period/s of time: \[Provide specific dates if known, or approximate period of time\] Dated 20 Signature Position \* Omit section reference as appropriate 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 ```html <table cellspacing="0" cellpadding="0" style="width:100%; border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="2" style="border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Claimant’s name</td></tr><tr><td colspan="2" style="border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Residential address</td></tr><tr><td style="width:74.62%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:25.38%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Postcode</td></tr><tr><td colspan="2" style="border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Postal address (if different from above):</td></tr><tr><td style="width:74.62%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:25.38%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Postcode</td></tr><tr><td colspan="2" style="border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Daytime phone no. ( ) Mobile no. (if any):</td></tr><tr><td colspan="2" style="border-top:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Email address (if any):</td></tr></tbody></table> ``` 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: ```html <table cellspacing="0" cellpadding="0" style="border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="10" style="width:354.35pt; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Account name (eg. Jan and John Citizen)</td></tr><tr><td colspan="3" style="width:211.8pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Name of financial institution</td><td colspan="7" style="width:131.75pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Branch:</td></tr><tr><td colspan="3" style="width:211.8pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">BSB number</td><td style="width:9.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:11.4pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">−</td><td style="width:9.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td></tr><tr><td style="width:171.6pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Account number</td><td style="width:9.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:11.4pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:9.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td></tr></tbody></table> ``` 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). ```html <table cellspacing="0" cellpadding="0" style="width:100%; border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="2" style="border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Claimant’s name:</td></tr><tr><td style="width:70.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Claimant’s signature:</td><td style="width:29.3%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Date / /</td></tr></tbody></table> ``` Schedule 5.1—Oath and affirmation of office (subregulation 5.03(1)) | Oath | I, [name], do swear that I will bear true allegiance to Her Majesty Queen Elizabeth the Second, Her Heirs and Successors according to law, that I will well and truly serve Her in the office of [name of office] and that I will faithfully and impartially perform the duties of the office. So help me God! | | ---- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | | I, [name], do solemnly and sincerely promise and declare that I will bear true allegiance to Her Majesty Queen Elizabeth the Second, Her Heirs and Successors according to law, that I will well and truly serve Her in the office of [name of office] and that I will faithfully and impartially perform the duties of the office. | Schedule 5.2—Information and copies of documents to be provided to the Minister and the Fair Work Ombudsman (regulation 5.04)