"Employee Application Form - Commuting Subsidy: Ferry Claim" - Queensland, Australia

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Employee application form - Commuting subsidy: Ferry claim
Eligibility requirements
To be eligible to make a North Stradbroke Island (NSI) ferry claim, you must:
have previously completed the employee application form and been approved for your nominated amount of commuting subsidy;
continue to reside on NSI; and
travel on the NSI ferries for the purpose of seeking employment, attending approved training, attending employment on the mainland or
attending other approved appointments by the ESM.
Commuting subsidy claims can be made for a minimum period of four weeks and a maximum period of six months. This means that claims
cannot be submitted more often than every four weeks. The commuting subsidy is available for up to two years from date of retrenchment,
or until your nominated individual cap is reached, or until the WAS ceases – whichever comes sooner.
Proof of eligibility:
Proof of employee identity (drivers licence or birth certificate as well as Medicare card)
Proof of payments for your travel on NSI ferries over the period (i.e. ferry receipts)
Proof of NSI residence (most recent rates notice or utility bill)
Applicant information
Sibelco employee
Office use only - ESM to complete
number:
Case number:
Title:
Surname:
Given name(s):
Date of birth:
Home address:
Home phone:
Mobile:
Email:
Commuting subsidy claim 
What date range does this claim relate to?
from
to
What is the total amount you are claiming for travel on NSI ferries, during the above date range?
$
Attending other ESM
Attending
Seeking
Attending
Purpose of travel
approved
employment
employment
approved training
appointments
Office use only – ESM eligibility assessment
Yes
No
Applicant bank details 
Account name:
BSB:
Account number:
Employee application form - Commuting subsidy: Ferry claim
Eligibility requirements
To be eligible to make a North Stradbroke Island (NSI) ferry claim, you must:
have previously completed the employee application form and been approved for your nominated amount of commuting subsidy;
continue to reside on NSI; and
travel on the NSI ferries for the purpose of seeking employment, attending approved training, attending employment on the mainland or
attending other approved appointments by the ESM.
Commuting subsidy claims can be made for a minimum period of four weeks and a maximum period of six months. This means that claims
cannot be submitted more often than every four weeks. The commuting subsidy is available for up to two years from date of retrenchment,
or until your nominated individual cap is reached, or until the WAS ceases – whichever comes sooner.
Proof of eligibility:
Proof of employee identity (drivers licence or birth certificate as well as Medicare card)
Proof of payments for your travel on NSI ferries over the period (i.e. ferry receipts)
Proof of NSI residence (most recent rates notice or utility bill)
Applicant information
Sibelco employee
Office use only - ESM to complete
number:
Case number:
Title:
Surname:
Given name(s):
Date of birth:
Home address:
Home phone:
Mobile:
Email:
Commuting subsidy claim 
What date range does this claim relate to?
from
to
What is the total amount you are claiming for travel on NSI ferries, during the above date range?
$
Attending other ESM
Attending
Seeking
Attending
Purpose of travel
approved
employment
employment
approved training
appointments
Office use only – ESM eligibility assessment
Yes
No
Applicant bank details 
Account name:
BSB:
Account number:
Applicant declaration
Privacy Statement: The Department of Employment, Small Business and Training collects your personal information in order to provide
assistance under the North Stradbroke Island Workers Assistance Scheme (WAS) for the purpose of administering the WAS. Your
information may also be provided to other Queensland agencies, agencies of other States, Australian Government agencies, local
government and non-government organisations including business entities, for the purpose of administering, monitoring, auditing,
evaluating and promoting the WAS. Your personal information will be managed in accordance with the Information Privacy Act 2009.
I,
(applicant’s full name) hereby declare that the
information I have provided is true and correct and that I have not previously applied for or received the same assistance measure under
the WAS. I understand giving false or misleading information to obtain a benefit from the Queensland Government is fraudulent and may
contravene section 408C of the Queensland Criminal Code.
I understand that the receipt of this subsidy/assistance may affect Commonwealth Support Payments (either in full or in part) and it is my
responsibility to make enquires with Centrelink on the impacts of payments under the WAS prior to applying for assistance.
I understand that direct debit payments will be made within 14 days of the submission of application form and supporting documentation by
Employment Services Manager.
I agree to repay any subsidy/assistance or overpayment made as a result of my providing incorrect information or being found to be ineligible
and the Queensland Government may refer cases of suspected fraud to the Queensland Police Service for investigation.
Applicant Name
Applicant Signature
Date
Employment Services Manager (ESM)
ESM Signature
Date
Yes
No
OFFICE USE ONLY: ESM Checklist - Confirm each item
Proof of payment for travel on NSI ferries
Total amount of ferry travel claim
$
Dates match to claim period
Total amount paid matches claim amount
Proof of ID attached
Proof of NSI residence attached (recent rates notice or utility bill)
NOTES (office use only) 
 
 
 
 
 
 
 
 
North Stradbroke Island – Commuting subsidy - Ferry Claim
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Version - August 2020
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