Salary Sacrifice Application Form - Child Care

Employee Information

First Name

Last Name

Employee ID

Job Title

Department

Date

No. of children

Days per week

Child's Name

Company Name

Address

Contact Number

Amount to be salary sacrificed

Effective Date

Frequency of Payment

Weekly

Fortnightly

Monthly

I hereby authorize my employer to deduct the specified amount from my pre-tax salary for the purpose of paying my child care fees to the designated provider.
I understand that the amount salary sacrificed will not be subject to income tax.
I acknowledge that I may be eligible for government subsidies for child care expenses.
I understand that this authorization may be revoked in writing at any time.

Employee Signature

Manager/HR Representative Signature

Not this one? Create your own forms like this with Zapof's auto-calculating tables and spreadsheet features!

This form is protected by Google reCAPTCHA. Privacy - Terms.