Capital Gains Withholding Clearance Certificate Application Service Declaration

By submitting this form, I declare that CGT Clearance (ABN 58 645 964 156) is authorised to act as my registered tax agent and to give the information provided in this form to the Commissioner of Taxation. I understand that CGT Clearance will utilise information supplied by me in this form to apply for a Capital Gains Withholding Clearance Certificate from the Australian Taxation Office (ATO) when requested. I confirm that I have received the consent of all individuals referred to in this application form, to the submission of their personal information contained in this form to CGT Clearance and to the ATO as necessary to process this application. I verify that the information supplied is, to the best of my knowledge, accurate and complete. I also confirm:

• I am not disqualified from managing corporations under Section 206B(1) of the Corporations Act 2001.
• Within the last 5 years I have not been convicted of, or released from prison after being convicted of, and serving a term of imprisonment for, any of the criminal offences referred to in Section 32(1)(c) or (d) of the Business Names Registration Act 2011.
• The information supplied is, to the best of my knowledge, accurate and complete.
• Penalties may be imposed for giving false or misleading information.
• Taxation law authorises the ATO to collect information and to disclose it to other government agencies. For information about your privacy go to www.ato.gov.au/privacy
• I have the TFN, date of birth and name, OR name, address and date of birth for all key people in my business.