Submit All Claim Forms Within 3 Months of the Approval Date

/ CLAIM FORM
TRANSPORT OF
DONATED FODDER

Submit all claim forms within 3 months of the approval date.

i.This assistance is only available to transport operators who transport donated fodder on behalf of community groups to a central location for the distribution to individual farm properties.

ii.Approval to the transport of donated fodder must be obtained from the NSW Rural Assistance Authority by the community group together with the transport operator prior to the fodder being transported.

iii.Claims in excess of those approved will not be paid.

iv.A copy of the approval to the transport of the donated fodder must be attached to this form.

v.Copies of tax invoices for the cartage of the donated fodder must be attached to this form.

1. DETAILS

BP Number:
Name of Organising Committee/Group who organised transport of donated fodder:
Name of Claimant (Transport Operator):

1. MOVEMENT DETAILS

Movt No / Date of Movement / Type of Fodder / Net Weight (Tonnes) / Loaded Distance (km) / Cost per km / Amount paid to Carrier
1 / // / $
2 / // / $
3 / // / $
4 / // / $
5 / // / $
TOTAL
Movt No / Movement from / Movement to
1
2
3
4
5

1. BANK ACCOUNT DETAILS

Please provide bank account details for payment of subsidy

Account Name :
Bank/Credit Union etc Name :
BSB : / Account No:

1. STATEMENTS

General Statement

Any person who knowingly and with intent to defraud the NSW Rural Assistance Authority or another person, files a claim for assistance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime under the Crimes Act 1900 and subjects the person to criminal penalties.

Privacy Statement

The information in this claim form is provided voluntarily and is being collected by the NSW Rural Assistance Authority for purposes related to the administration of the scheme of assistance under which you have applied, including the assessment of the effectiveness of the scheme. This may involve disclosing the information in this claim to contractors engaged by the Authority or to either State or Commonwealth government agencies. We will supply you with details of those that we have disclosed information to, if you apply to us in writing.

Not providing the information requested in this claim form or providing false or misleading or incomplete information may impact on the ability of the Authority to accurately assess the claim.

The NSW Rural Assistance Authority agrees to take all reasonable measures to ensure that the personal information collected by it is stored securely.

You may access or correct your personal information by contacting the Authority by telephone on 1800 678 593 (toll free) or by writing to: Manager Administration, NSW Rural Assistance Authority, Locked Bag 23, ORANGE, NSW, 2800. Calls to “1800” numbers from your home phone are free. Calls from public phones and mobiles may be timed and attract charges.

1. ORGANISING COMMITTEE/GROUP DECLARATION

I, (full name) ______

of______

in the State of New South Wales, being an official of an Approved Community Organisation, do hereby solemnly and sincerely declare and affirm that the assistance claimed on this form relates to the movement of donated fodder to feed stock on drought/disaster (please delete whichever is not applicable) affected properties in the area/s detailed above in section 2.

Signed______(Official of Approved Community Organisation)

Declared at ______on____ / _____ / ______

1. TRANSPORT OPERATOR (CLAIMANT’S) DECLARATION

I, (full name) ______

of______

in the State of New South Wales, do hereby solemnly and sincerely declare and affirm that:

1.I have read the latest Scheme Information and Guidelines in relation to the assistance applied and understand the conditions and requirements therein; and

2.the distance travelled was the shortest practical route.

I understand that:

3.funds for the scheme are limited and that claims for transport of donated fodder in excess of the approved amount/s will not be paid;

4.deliberately giving false or misleading information is a serious offence;

5.the NSW Rural Assistance Authority can make relevant enquiries to ensure I receive my correct entitlement;

6.any overpayment will be recovered;

7.personal information is protected and can be given to someone else where state/territory or Commonwealth legislation requires or where I give permission;

8.statistics may be collected and analysed in such a way as to protect my anonymity.

I do solemnly and sincerely declare that the particulars on this form and associated with this application are true and correct.

I agree to provide feedback in relation to this Scheme.

Signed______(Transport Operator)

Declared at ______on____ / _____ / ______

1. RECIPIENT CREATED TAX INVOICE AGREEMENT AND DECLARATION

The RCTI component of this agreement is made in accordance with A New Tax System (Goods and Service Tax)Act 1999 Classes of Recipient Created Tax Invoice Determination (No. 1) 2000 betweenNSW Rural Assistance Authority (ABN 17 283 358 394) having its head office at 161 Kite Street, Orange, New South Wales, 2800 (the “Recipient” and “Authority”) and

Name of Applicants / Address of Applicants
ABN : / ABN :

together referred to as the Parties.

In this agreement:

“Adjustment Event”, “Adjustment Note”, “Taxable Supply” have the meaning given to them in the GST Law.

“Determination” means Determination of the Commissioner of Taxation set out as schedule 1 to Goods and Services tax

Ruling GSTR2000/10 entitled “Goods and Services tax: recipient created tax invoices”.

“GST” means goods and services tax.

“GST Law” means A New Tax System (Goods and Services Tax) Act 1999.

“RCTI” means a recipient created tax invoice that satisfies the requirements of the GST Law and associated rulings and determinations, the Determination

A. RCTI
The Parties agree that:
The Recipient:

1. may, within twenty eight (28) days of making or determining the value of the Taxable Supply that is related to the Transport of Donated Fodder, issue an RCTI in respect of that supply (whether paid in one or more amounts);

1. must not issue a document that would otherwise be an RCTI, on or after the date when the Recipient of the Supplier has failed to comply with any requirement of this agreement;

1. acknowledges that it is registered for GST at the time this agreement is executed and the Recipient will notify the Supplier if the Recipient ceases to be registered;

1. will issue to the Supplier an Adjustment Note in relation to Adjustment Events within twenty eight (28) days of the Adjustment Event to which the Adjustment Note relates;

1. will reasonably comply with its obligations under the taxation laws.

/ The Supplier:

1. will not issue tax invoices in respect of the Transport of Donated Fodder;

1. acknowledges that the Supplier is registered for GST at the time this agreement is executed and will immediately notify the Recipient if the Supplier ceases to be registered.

B. DECLARATION
The Applicant:

1. declares that the information provided in the Transport of Donated Fodder claim form is true and correct at the time of lodgement; and

1. undertakes to contact the Authority immediately if the information provided in the Transport of Donated Fodder claim form changes; and

1. agrees to the terms and conditions set out in the Transport of Donated Fodder claim form including the privacy statement; andagrees to participate in any follow up survey if requested by the Authority to do so.

Signed as an agreement by the Parties to the terms and conditions set out herein.

Signed______(Transport Operator)

Date:____ / _____ / ______

Signed for and on behalf of the NSW Rural Assistance Authority (ABN 17 283 358 394): ______

Date:____ / _____ / ______

1. LODGEMENT OF APPLICATIONS

Applicants can lodge completed application forms including required documentation with the NSW Rural Assistance Authority by post, email, facsimile or personal delivery at:

Post: Locked Bag 23

Orange NSW 2800

Email:

Fax: (02) 6391 3098

In person: 161 Kite Street

Orange NSW 2800

Telephone:1800 678 593 (Toll Free)

Website:

Applications must be received by the NSW Rural Assistance Authority no later than the closing date.Applications received after the advertised application period closing date,
in any other circumstances will not be accepted.

If you have difficulty understanding or completing this form you should seek the assistance of your rural/financial counsellor, business advisor, accountant or a trusted family member/friend.

Language Services (Interpreting and Translating) are available by contacting Multicultural NSW
on 1300 651 500 or by visiting .

NSW Rural Assistance Authority Claim Form - Transport Subsidy for Donated Fodder V 3.0 02/18Page 1