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 THIS 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 NUMBER: - 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 Person:		
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	
Date of application: (dd/mm/yyyy):_______________________________________	
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. 
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.	
Date:_____________________________________	Signature:________________________________________	
This Nomination will take effect from (dd/mm/yyyy)	_______________________________________________	

GIVING FALSE OR MISLEADING INFORMATION IS A SERIOUS OFFENCE (Criminal Code 2002)	
Privacy Statement - All information collected by the ACT Revenue Office is protected by secrecy provisions in Acts administered by the Office and only used for the purposes of those Acts. In addition, personal information provided to the ACT Revenue Office is protected by the Information Privacy Act 2014. Information (including personal information) is not disclosed to any third party unless authorised by law or with the consent of the person involved.	

Revenue Office Contact Details
Telephone	(02) 6207 0028	
Email	dmr@act.gov.au	
Facsimile:	(02) 6207 0090	
Postal address	PO Box 293
Civic Square  ACT  2608	
Website	http://www.revenue.act.gov.au