Download Change to Salary Packaging Arrangements Form - JAWS

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CHANGE TO SALARY PACKAGING ARRANGEMENTS FORM
AccessPay logo
This is the form to use when you need to change your payment details, the amount you package or your payments. Please attach the relevant
supporting documentation. Refer page 2 for examples. If you need to contact us about this form you can contact us on telephone 13 00 13 36 97,
facsimile 13 00 36 14 98, email [email protected], postal address GPO Box 1238, Adelaide SA 5001. Upon completion of this
form please print, sign and return to AccessPay. Alternatively we will accept an unsigned email.
Personal details
Employer Name:
Your Address:
Surname:
Given Names:
Email Address:
Date of Birth:
Payroll number:
Phone number:
AccessPay subscriber number:
Change options
Please consider if this change will need to revert to your previous arrangements
For how many payments would you like this change to occur? Please select one option only by entering an ‘X’ in the cell adjacent to the
correct option.
Once off – you would like this change to occur for one (1) pay period only
Short term – you would like this change to occur for a prescribed number of pay periods
Ongoing – you would like this change to continue until you advise AccessPay otherwise.
If Short Term has been selected, please indicate the number of pay periods
If Once off or Ongoing has been selected, please indicate the amount per pay period
From the following two options which date would you like this change to occur? Please allow sufficient time for the changes to be applied
Next available pay period? (enter an ‘X’ in the cell adjacent)
A Nominated date effective for changes? (enter the date of your next pay day)
Please indicate what date you wish for the change to revert back on
List all payment you want AccessPay to make per pay period. To stop a payment please write ‘STOP’ in the Total Field
Please provide a
description payment.
Attach supporting
documents
Example: Mortgage
Is the expense to be
paid fortnightly,
weekly or monthly?
Fortnightly
Is the expense to be
paid by Electronic
Funds Transfer (EFT)
or BPay?
EFT
Please provide
details of the BSB
or BPay Biller Code
123-456
Please provide the
account number or
BPay Reference
Number
221322587
Total
84.32
Plus AccessPay fee
New Total Salary Packaged Amount
Declaration
I request that the changes shown on this form be made to my salary packaging arrangements and confirm my continuing compliance with my employer’s
policies and procedures. I also confirm that any reimbursement request is in relation to expenses already paid by me.
Signature
Dated
Note: It is your responsibility to notify AccessPay immediately of any changes to this authority. You need to inform AccessPay of any change to
your remuneration package.
Please ensure you provide all supporting documentation relevant to your payment requests to avoid any delay in the commencement of your
salary packaging arrangement.
Supporting Documentation examples
Examples of Expense Benefits
Supporting Documentation Required
Mortgage or Personal Loan (NOT investment properties)
Account details, amount owing and proof of two consecutive payments
Rent
Name, address, amount to be paid, payment details, end date or length of lease and
two consecutive payments.
Credit Card
Card number, payment details, date of statement, closing balance. If reimbursement,
detailed transactions showing proof of payment and date.
Education Payments (including School Fees, Child Care,
HECS/HELP repayments)
Name, school, date, amount owing payment details. If reimbursement, proof of
payment.
Salary Packaging Card
NAB Application form. If you aren’t a current NAB Customer please go to a branch,
show 100 points of ID and note your Customer Number on the Application Form.
Private Health Insurance
Policy or Member Number, amount owing, payment details, name, address, frequency
of payment, period of cover date or date letter was issued, proof of payment
Household Bills (including Council Rates, Water Rates,
GST and non-GST purchases)
Name of Supplier, Date, amount owing, payment details, description of goods
purchased, Tax Invoice, amount of GST (if any) payable, proof of payment, supplier
ABN
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