Industry contribution levy dispute form

This form is to be completed by a reporting entity that wishes to lodge a dispute regarding all or part of the amount of the industry contribution and/or late payment penalty levied by AUSTRAC.

If you would like to ask a question before lodging a dispute form please email LevyInvoice@austrac.gov.au.

Your contact details

Company

Contact name

Phone

Your role

AUSTRAC account number/s (AAN)

Your financial year end date

e.g. 30 June

Invoice details

Invoice date

Invoice number/s

Invoice/s amount ($)

Dispute details

Earnings data

Transaction data

Other enrolment data

Other (please select option below and provide further detail in next section)

Yes

Current levy invoice

Multiple year/s

Please outline and provide your earnings figure for each disputed year in the reasons box below or in uploaded supporting documentation.

Yes

Evidence of declared earnings

Upload your supporting documents or provide a link to your financial statements.

Upload supporting documents

Maximum 4 files.
Allowed types: pdf doc docx xls xlsx.
10 MB limit per file. The accumulated size of all files in this form cannot exceed 20 MB.

Ensure you include the full URL including 'https://' at the start

Circumstances in support of this application

Please outline the reasons for the dispute in the text field below or upload a supporting letter.

Letter upload

One file only.
Allowed types: pdf doc docx.
10 MB limit per file. The accumulated size of all files in this form cannot exceed 20 MB.

Declaration statement

I declare that:

I am authorised to complete this form on behalf of the applicant(s).
If/where incorrect, the information on the Reporting Entities Roll pertaining to the applicant(s) has been updated to reflect the true and correct information about the applicant(s).
I understand criminal or civil penalties may apply for giving false or misleading information, or for failing to supply information.
I agree that the information provided on this form is true and accurate.

Declaration statement agreement

Privacy collection statement

AUSTRAC may collect personal information including names, contact details, job titles and any other personal information contained within any responses or attachments to this web form, for the purposes of administering the AUSTRAC industry contribution levy. How AUSTRAC collects and manages your information is available through our privacy collection statement.