Document ID: chunk:federal_register_of_legislation:F2024C00882:schedule:10:p1
Version: federal_register_of_legislation:F2024C00882
Segment Type: schedule
Provision Reference: sch 10 (pt 1/10)
Character Range: 537643–539205

Schedule 10—Employer authorisation—prescribed form of statement
Note: See subregulation 28LCE(2).

         [Form]  Consent to make direct deductions from salary or wages

Subsection 160E(2) of the Act
[Regulation 28LCE of the Regulations]

TO:    . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(name of employer of debtor/lessee)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(address of employer of debtor/lessee)

FROM:   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(name of credit provider/lessor)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Australian credit licence number)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(address of credit provider/lessor)

Complete all of the following information (except as indicated) before signing the form

Date of first deduction:
Date of last deduction:
Amount of each deduction:
IMPORTANT
YOU CAN CANCEL THIS DEDUCTION REQUEST DIRECTLY WITH YOUR EMPLOYER AT ANY TIME.
IF YOU CANCEL THIS DEDUCTION REQUEST YOU WILL BE IN DEFAULT IF YOU DO NOT MAKE ALTERNATIVE ARRANGEMENTS TO MAKE REPAYMENTS.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(signature of debtor/lessee giving consent)

I confirm I have been provided with a copy of this form.
. . . . . . . . . . . . . . . . . . . . . . .