Self Employed declaration form

Complete this form if there is a self-employed person in your household.
Please return completed form to your nearest Housing Service Centre.
Application/Tenancy reference number:
Name of self-employed person: Address:

Name of company/business Australian Business Number (ABN) Type of self employed business
Address of your self employed business

ABN

Details of business

Date that your self employed business commenced
Date that you lodged your first Business Activity Statement

Income from business
Gross takings for previous calendar month

CRN

Do you also receive a part Centrelink income?	Yes	No If Yes, what Centrelink payment do you receive?
What is your Centrelink Customer Reference Number
Please attach evidence of the start date of your business and earnings to this form.
EG: a letter from your accountant
Signature:	Date
Self Employed Household Member

Privacy Notice
The Department of Housing is collecting your personal information so we may provide you with housing assistance. To assist you with your housing needs and services, your personal information may be disclosed to partner agencies, service providers, local governments and non-governmental agencies that now, or will, provide you with housing and/or support services. Unless authorised or required by law, your personal information will not be disclosed to any other third party without your consent. More information about the Department’s privacy obligations is available on our website at www.housing.qld.gov.au.
DECLARATION
To the best of my knowledge, the information provided on and in conjunction with this form is true and correct. I/ We understand that it is an offence liable to a penalty under the Housing Act 2003 and/or a breach of my State Tenancy Agreement to knowingly provide false or misleading information to the Department of Housing.

Tenant/applicant name: Signature: Tenant/applicant name: Signature:

Date	 	

Date

Department of Housing
www.housing.qld.gov.au

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PH188 SelfEmployedDeclaration (24/07/2023)