ACT Revenue Office
ABN: 45 096 207 205	
Payroll Tax Act 2011

Application to nominate a Designated Group Employer (DGE) or a 
Joint Return Lodger (JRL) for ACT Payroll Tax

An ACT employer which is part of a group, may claim the group’s entitlement to the ACT proportion of the tax-free threshold, provided it is an approved Designated Group Employer (DGE).

An applicant for DGE status (or an existing approved DGE) may also apply to become a Joint Return Lodger (JRL) for itself and other ACT group members.

COMPLETE ALL SECTIONS OF THE FORM

Client Reference Number 
	If already registered with the ACT Revenue Office for any other tax or duty, provide the existing client reference number		
ACT Payroll Tax Group No. 	Provide if known		
SECTION A:  Nomination of a Designated Group Employer  – Name of Company, Association, Trustee, Partnership/Joint Venture or Individual (full legal name - if space is insufficient attach a separate sheet)

	

ABN		ACN		

Trading Name or Trust Name		

ACT Business address  	
	
Postal address 
(for Service of Notices)	

Contact Officer		
Telephone		Facsimile		
Email address 		
SECTION B:  Application to nominate the DGE identified above as the JRL
Do you nominate the DGE identified above to be the JRL for all the ACT group members listed on this form?	YES	NO	
SECTION C:  List other ACT Group Members paying wages in the ACT (if space is insufficient attach a separate schedule) 

Client Ref. No.	Legal Name	ABN	Date of joining group	

				

List other Group Members outside the ACT (if space is insufficient attach a separate schedule)

Legal Name	ABN	Date of joining group	

			
			
SECTION D:  Declaration - The ACT Revenue Office relies on the information provided in this application to establish a DGE or a JRL for ACT payroll tax purposes.  Please ensure the information provided is correct. 
The Criminal Code 2002 contains serious offence provisions for making, giving or producing false or misleading statements, information or documents for which the maximum penalty is 100 penalty units or imprisonment for one (1) year or both, and 500 penalty units or imprisonment for five (5) years or both if the false statement is knowingly made in a statutory declaration.

I,_________________________________________ , ____________________________________________	
(full name)	(position)	
of ____________________________________________________________________________________	
(name of employer or firm acting for employer)	
declare that the information provided in this application is true and correct. 

This nomination is to take effect from (dd/mm/yyyy)     __________________________________	
Application Date:___________________________	Signature:__________________________________	
Mail the completed forms to	ACT Revenue Office
PO Box 252
CIVIC SQUARE ACT 2608	
Or send by facsimile to	(02) 6207 0090	
Phone enquiries	(02) 6207 0079
(02) 6207 0088	
Privacy - The information in this form is required by the ACT Revenue Office to determine your ACT payroll tax liability and is authorised by the Payroll Tax Act 2011 and the Taxation Administration Act 1999.  The information can only be disclosed to another party in the circumstances outlined in the Taxation Administration Act 1999. In addition, personal information provided to the ACT Revenue Office is protected by the Privacy Act 1988 (Cwlth).  Information (including personal information) is not disclosed to any third party unless authorised by law or with the consent of the person involved.