PAYG Payment Summary Statement for Year Ending 30 June 2018

PAYG paymentsummary statementThis form is part of the PAYG payment summary annual report. See reverse of page for how to complete this form. If you report your payment summary information to uselectronically, do not complete this form. Payment summaries printed from payroll software should not accompany this form. Use ATO printed payment summary forms.Print clearly in BLOCK LETTERS with a black pen only. Do not use rubber stamps to show payer details. Complete and send this form to us by 14 August withthe ATO original of the payment summaries issued. Do notuse this form if you report using electronic media.Send your completed form to us at: Australian Taxation Office Locked Bag 50 PENRITH NSW 2740If you are amending a payment summary statement you have already sent, place X in this boxNAT 3447-02.201434470214 You will need to keep a copy of this completed form, together with the PAYG payer’s copy of the payment summaries issued, for your records.Statement for year ending 30 JunePayment summaries issuedPayment summary type Total of amounts of tax withheldTotal number ofpaymentsummaries issuedTotal of gross payments ortaxable componentsIndividual non-business (includessalaries or wages paid to employees) .00$ , , .00$ , ,Employment termination payment .00$ , , .00$ , ,Superannuation lump sum .00$ , , .00$ , ,Superannuation income stream .00$ , , .00$ , ,Business and personalservices income .00$ , , .00$ , ,Foreign employment .00$ , , .00$ , ,Privacy – For information about your privacy, visit our website at ato.gov.au/privacyDeclaration I declare that the information given on this form is complete and correct.Signature ofauthorised person DateDay Month YearNameContact name Contact phone numberAddress PostcodeSuburb, town or locality StatePayer details Branch numberABN or withholding payer number 1 1 1 1 1 1 1 1 1 1 1
2 0 1 8
1 1 1
JOHN DOE
0 2 0 7 2 0 1 8
9 9 9 2 0 2 6 7 3 4
1 1 1 1 1 1
Street number and street name
R O C K W O O D
4 9 6 0
5 0 0 0
L T D
E M I L Y B A F F
0 0 0 A B C A V E N U E
S U B U B I A V I C 3 0 0 11 1 1