Employer’s declaration form

Section A - tenant/applicant/household member to complete	
Application/Tenancy reference number:		
Name:
Address:		
		
Section B – your employer/s to complete this section to supply evidence of your income	
Name of employer (or company name/stamp)		
Occupation of the person named in section A		

/	/

Permanent

Temporary

Casual

Fulltime

Part-time

*School year only

/	/

*If school year only, is the employee paid during the school holidays? Date employment began:	Date ceased (if applicable)

Yes	No

Income received – fulltime and permanent part-time employees only	
Gross weekly wage/salary * $		Employee has been receiving this rate of pay since (date):		

/	/

*Total gross weekly wages includes income which is salary sacrificed; paid as a fringe benefit; and, wages paid while the employee is on leave. Please DO NOT include ‘other’ income types listed below.

Income received – casual / part-time employees only	
Total gross casual earnings for last four weeks (or less if employed less than 4wks)	$		
Please do not include other income e.g. overtime, bonuses, allowances, etc, (see 'other income' below)

Other income (not included in gross wage above)	Total for last four weeks	
Commission/s	$	
Work allowances (DO NOT include allowances that are reimbursements for actual expenses e.g. travel, tools or clothing)	$	
Overtime	$	
Bonuses	$	
Leave loading	$	
Other (please specify)	$	
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 - employer/company representative to sign

	Date:		
	Phone:		

Signature:

/	/

Print name:
Position:

Please return completed form to your nearest Housing Service Centre.

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

PH016 (24/07/2023)