SUBCONTRACTOR’S STATEMENT

REGARDING WORKERS COMPENSATION, PAY-ROLL TAX

New South Wales AND REMUNERATION (Note 1)
† Workers Compensation † Pay-roll tax † Remuneration
s175B Workers Compensation Act 1987 Part 5B s31G-31J Pay-roll Tax Act 1971 ss127, 127A Industrial Relations Act 1996

Sub Contractor: _______________________________________ ABN: ________________________

(Business name)
of __________________________________________________________________________________
(Address of subcontractor)
has entered into a contract with_______________________________________________________(Note 2)
(Business name of principal contractor)
ABN: ______________________ For work between: / / and / / (Note 3)
Date Date
and/or Payment Claim Details: ________________________________________________________(Note 4)
Nature of contract work: _____________________________________________________________(Note 5)

DECLARATION
I, _________________________________ a Director of / a person authorised by the subcontractor on whose behalf this
(delete as appropriate)
declaration is made, hereby state that the abovementioned subcontractor:

Is either
‰ A sole trader or partnership without workers or subcontractors (Note 6).
OR
‰ Has and will maintain in force valid workers compensation insurance, policy _______________________
(Policy Number)
held with ______________________________________ as indicated on the attached Certificate of
(Insurance Company)
Currency dated ___________________, in respect of work done in connection with the contract, during
any period of the contract and has paid all workers compensation insurance premiums payable in
connection with the contract (Note 7).
‰ Is ‰ Is not also a principal contractor in connection with the work under contract (Note 8).
‰ Has ‰ Has not been given a written statement by subcontractors in connection with the work.
‰ Is ‰ Is not required to be registered as an employer under the Pay-roll Tax Act 1971 ________________.
(Pay-roll tax client No.)
‰ Has paid all pay-roll tax due in respect of employees who performed the work for the principal contractor, as
required at the date of this statement (Note 9).
‰ Has paid all remuneration payable to relevant employees, for work done under the contract during the period
outlined above (Note 10).

Signature _________________________________ Full Name _______________________________

(please print)
Position/Title ______________________________ Dated _______________________________

WARNING
• Any subcontractor, who knowingly provides a principal contractor with a written statement that is false, is guilty of an
offence (Maximum penalty 100 units or $11,000).
• Any written statement will not relieve the principal contractor of liability if, at the time the written statement was provided,
the principal contractor believed the written statement to be false.
• The principal contractor must retain a copy of any written statement for a period of not less than five years (Pay-roll tax),
six years (Remuneration) or seven years (Workers compensation).
• This statement must be accompanied by the relevant Certificate of Currency to comply with section 175B of the Workers
Compensation Act 1987
 NOTES
1. This form is prepared for the purpose of section 175B of the Workers Compensation Act 1987,
Part 5B section 31G-31J of the Pay-roll Tax Act 1971 and section 127 of the Industrial Relations
Act 1996. If this form is completed in accordance with these provisions, a principal contractor is
relieved of liability for workers compensation premiums, pay-roll tax and remuneration payable by
the subcontractor.
2. For the purpose of this statement, a principal contractor is a person (or other legal entity), who has
entered into a contract with another person (or other legal entity), referred to as the subcontractor,
and employees/workers of that subcontractor will perform the work under contract. The work must
be connected to the business undertaking of the principal.
3. In order to meet the requirements of s127 Industrial Relations Act 1996, a statement in relation
to remuneration must state the period to which the statement relates.
Section 127(6) Industrial Relations Act 1996 defines remuneration as ‘remuneration or other
amounts payable to relevant employees by legislation, or under an industrial instrument, in
connection with work done by the employees.’
Section 127(11) of the Industrial Relations Act 1996 states ‘to avoid doubt, this section extends
to a principal contractor who is the owner or occupier of a building for the carrying out of work
in connection with the building so long as the building is owned or occupied by the principal
contractor in connection with a business undertaking of the principal contractor.’
4. Payment claim details – Where a subcontractor has entered into a payment schedule with a
principal contractor they must identify the period or payment to which the statement applies.
5. An accurate description of the work covered by the contract must be included.
6. In completing the statement, a subcontractor declares that they are a sole trader or partnership
without workers or subcontractors and is not required to hold workers compensation insurance.
7. In completing the statement, a subcontractor declares that workers compensation premiums
payable up to and including the date(s) on the statement have been paid, and all premiums owing
during the term of the contract will be paid.
8. It is important to note that a business could be both a subcontractor and a principal contractor, if
a business ‘in turn’ engages subcontractors to carry out work. If your business falls within this
category you should also obtain statements from your subcontractors.
9. In completing the statement, a subcontractor declares that all pay-roll tax payable relating to work
undertaken as part of the contract has been paid.
10. In completing the statement, a subcontractor declares that all remuneration payable has been
paid.
It is noted that definitions of employer, employee, remuneration, and specific provisions for
employers of outworkers in the clothing trades are as defined in s127A of the Industrial Relations
Act 1996.
11. Failure to complete this statement may result in the principal contractor withholding any payment
due to the subcontractor. Any penalty for late payment under the contract does not apply to any
payment withheld under this subsection. Subcontractors may wish to keep a copy of the statement
for their own records.
For more information, please visit the WorkCover website www.workcover.nsw.gov.au, Office of State
Revenue website www.osr.nsw.gov.au, or Office of Industrial Relations, Department of Commerce
website www.commerce.nsw.gov.au. Copies of the Workers Compensation Act 1987, the Pay-roll Tax
Act 1971 and the Industrial Relations Act 1996 can be found at www.legislation.nsw.gov.au.