fikaticost--t emeteN co 0018 r- Aswan Gann Dopers Vass Unica centrelink Employment Separation Certifical This document certifies employment information. Please read the information on page 2 before completing this form. Please note: Personal information is protected by law and can be given to someone else only in special circumstances, where Commonwealth legielat requires or where you give permission. Giving false or misleading information is a serious offence. 1. Employee details (Former employees please see Important information on the back of this form.) Family name Date of birth Date employee started working for you 2/ Date employment ceased 2. Reason for separation Shortage of work Unsuitability for this type of work End of season or contract Redundancy First given name Address Unsatisfactory work performance Misconduct as an employee Employee ceasing work voluntarily , Other L Postcode Please give reason and/or further details 3. Has a claim been made, or Is a claim likely to be made, for workers compensation? No . Yes-1 4. What wasns the person's final gross payment including leave and redundancy payments? 5. Old you pay (in the last 12 months), or will you pay the person, any unused leave entitlements or final gross redundancy payments on termination? ! No Yes[) Provide details below Type o' leave Date paid/ to be pap Period covered (number of working days( Gross amount $ • Redundancy f S [In lieu of notice !Gratuity or golden handshake / I S s Sick Leave i I Rostered days off i • $ Annual leave Maternity Leave :S S Long Service Leave I • day %Neu* 5 Other - • IS 6. If the person was paid a redundancy payment, in lieu of notice of grataity, what was the person's average gross weekly wage? (see page 2 — Definition) 7. In the last 12 months, did this person cash in any leave entitlements for money before finishing work? Number of working days i Amount 5 (gross) Type of lease .._.._ _. . .