MEDICAL SERVICES GROUP 2017 Income Tax Information

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1 MEDICAL SERVICES GROUP 2017 Income Tax Information Full Name Home Address Postal Address (if different from above) Occupation / Speciality Date of Birth Phone (W) Mobile Tax File Number Phone (H) BANK ACCOUNT DETAILS The Australian Taxation Office no longer issue cheques for income tax refunds. If you are entitled to a refund it will need to be credited direct to your bank account. Please provide your bank account details: BSB No. Account No. Bank Account in name of Were you a resident for the full financial year? YES NO If no, please give details Do you have an outstanding HELP/AUSTUDY supplement loan? YES NO Spouse Name Tax File Number Taxable Income $ Spouse Reportable Fringe Benefits $ Spouse Reportable Super Contributions $ Children Name Name Name Notes: Date Received Health Services Group 2017 Income Tax Information (1)

2 MEDICAL EXPENSES AND PRIVATE HEALTH INSURANCE 1. Medical Expenses Rebate Net Medical Expenses (after Medicare, NDIS* and private health rebates) if in excess of the thresholds below: $ Note: Only medical expenses relating to disability aids, attendant care or aged care are eligible to be claimed. Thresholds: Single Income $0 to $90,000 $2,265 Family Income $0 to $180,000 $2,265 Single Income $90,000+ $5,343 Family Income $180,000+ $5, Private Health Insurance and Medicare Levy Are you eligible to receive Government Medicare Benefits? YES NO Are you covered by Private Health Insurance? (attach fund annual statement) YES NO Membership Number: Fund: Level of Cover: Hospital / Extras / Both (please circle) Days covered during the year: Rebate Claimed? YES NO If couple with family, are all family members covered? YES NO INCOME 1. PAYG Payment Summaries (attach summaries) No: 2. Other work related to Private Practice Income? (Untaxed) YES NO Please provide details and/ or attach Business Activity Statements (BAS) and BAS working papers/ calculations (if not prepared by Perks). Please detail other sundry untaxed income below. Source Amount $ Source Amount $ 3. Distributions from Trusts or Partnerships YES NO Managed Funds, eg Colonial First State, BT Funds, ING Funds etc attach annual tax statements. Family (Discretionary) Trust or Partnership attach financial statements and tax return. 4. Interest Earned Bank BSB Account No. Interest Amount TFN Withheld 5. Dividends Received attached dividend statements Name of Company SRN/HIN Unfranked Amt Franked Amt Imputation Credit TFN Withheld 6. Investment Rental Property if yes, complete attached schedule YES NO Was the property sold? If yes, completed attached schedule YES NO 7. Sale of Shares or other Investments if yes, please provide detail YES NO 8. Other Income attach relevant documentation YES NO Eg. - Superannuation Eligible Termination Payments (ETP) - Foreign Employment, Investment, Rental or Other Income - Primary Production Investments Other * National Disability Insurance Scheme Health Services Group 2017 Income Tax Information (2)

3 DEDUCTIONS Please do not include any expenses already detailed on your BAS or claimed through your Professional Development Fund or Salary Sacrifice Account. 1. Accounting/ Tax Agent Fees incl. Salary Sacrifice Consultations: $ 2. Professional Equipment and Library (under $300 per item): $ 3. Professional Equipment and Library (over $300 per item) Date Item Details $ Cost Work Use % Computer/ Laptop/ Personal Organiser Home Office Desk/ Bookcase/ Shelving Professional Reference Library Other Equipment Other Equipment 4. Donations/ Building Funds/ Political Parties Receipts YES NO Charity $ Charity $ Charity $ Charity $ 5. Income Protection Insurance: $ (Premiums paid excluding Trauma or Life Insurance) 6. Motor Vehicle Travel (Study Group/ Lectures/ Conferences/ Call Backs/ Other) Make, Model & Registration Date Purchased Cost: $ (if a new car was purchased during the year, please attach the tax invoice and finance documents) Logbook details if applicable Period Maintained: Business % (1) Cents per Kilometre Method (66 cents per km capped at 5,000km) OR (2) Log Book Method Based upon a reasonable estimate of travel Complete if logbook maintained Kilometres travelled between: Repairs & Maintenance: $ Locations Kms X Times/ Week X No. of Weeks = Insurance: $ X X = Registration: $ X X = Leasing/ Finance Costs: $ X X = Fuel and Oil: $ X X = Other: $ X X = Other: $ X X = 7. Stationery/ Postage, etc Receipts YES NO Printing, Stationery & Photocopying: $ Other: $ Repairs & Maintenance of Equipment: $ Other: $ Computer Expenses/ Accessories: $ Business % Health Services Group 2017 Income Tax Information (3)

4 8. Seminars/ Conferences/ Study & Exam Expenses Receipts YES NO (excluding costs reimbursed from PD Funding) Date Paid Description Fees $ Air Fares $ Meals $ Taxis $ Accom $ Other $ Was the duration longer than six nights? YES NO If yes, did you keep a travel diary YES NO 9. Subscriptions/ Professional Associations/ Medical Board/ Insurance (not reimbursed from PD) Registration: $ SASMOA: $ Other: $ Medical Defence: $ AMA: $ Other: $ RACGP: $ Other: $ Other: $ College Fees: $ 10. Internet Costs: $ Work/Business % Deduction $= 11. Telephone Home Office (work related calls only) Costs: $ Work/Business% Deduction$ or No. of Calls (local) per week X No. of weeks = Cents = Calls to STD/ Mobile per week $ X No. of weeks = 12. Telephone Mobile Calls & Rental Charges: $ Business % Deduction $ = 13. Electricity Home Office (advise average weekly hours for work use) Hours X No. of Weeks X ATO Rate ($0.45) Deduction $ = 14. Other Work Related Expenses (eg. Drugs & Supplies/ Taxis/ Parking Fees) Receipts YES NO Details: $ Details: $ Details: $ Details: $ Details: $ Details: $ 15. Superannuation Contributions Have you made a personal superannuation contribution in 2016/17 YES NO Have you completed the section Notice of Intent to Claim a Deduction for Personal Superannuation Contributions? YES If yes, please provide the Acknowledgement of Intent to Claim a Deduction letter from your superannuation fund/s. NO If no, please complete the Notice of Intent to Claim a Deduction and forward to your relevant fund/s ASAP. Please also provide a copy with this form. Health Services Group 2017 Income Tax Information (4)

5 INVESTMENT (RENTAL) PROPERTY Year Ending 30 June Name of owner(s) Address of property Number of weeks rented during the year Rent received $ Deductions Amount ($) Deductions Amount ($) Advertising $ Insurance $ Agents Commission $ Interest $ Bank Charges $ Land Tax $ Borrowing Costs $ Repairs & Maintenance $ Council Rates $ Water Rates $ Cleaning $ Depreciation $ Pest Control $ Emergency Levy $ Inspection Costs $ Lawn Mowing/ Gardening $ Travelling pre 9 May 2017 $ Electricity/ Power $ Other $ Other $ Furniture/ fittings purchased for the rental property during the financial year including GST Description of Item Date of Purchase Cost ($) Fixtures & Fittings Floor Coverings Furniture Hot Water Service Stove & Oven Curtains & Blinds Washing Machine & Dryer Air Conditioning Other Other PLEASE NOTE: As per Tax Office guidelines, it is recommended that you obtain an official report from a quantity surveyor to assist in the determination of depreciable items purchased in a new investment property. Health Services Group 2017 Income Tax Information (5)

6 Disposal of Rental Property Address of property Date acquired Cost Settlement Statement for Acquisition Provided: YES NO Major improvements to the Property During Ownership 1. Description Date Completed Cost $ 2. Description Date Completed Cost $ 3. Description Date Completed Cost $ Date Sold Proceeds from sale $ Settlement Statement for Sale Provided: YES NO Dates in which the owners resided in the rental property Health Services Group 2017 Income Tax Information (6)

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