Document ID: chunk:federal_register_of_legislation:F2024C01158:reg:1503:p5
Version: federal_register_of_legislation:F2024C01158
Segment Type: reg
Provision Reference: reg 1503 (pt 5/27)
Character Range: 298803–301828

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

Claimant's name
Residential address
                                                   Postcode
Postal address (if different from above):
                                                   Postcode
Daytime phone no. (       )  Mobile no. (if any):
Email address (if any):

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:

Account name (eg. Jan and John Citizen)
Name of financial institution            Branch:
BSB number                                              −
Account number

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).

Claimant's name:

Claimant's signature:  Date    /     /

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