Salary Packaging Benefit Confirmation Form

Recurring reimbursement declaration*

	Expense type (eg mortgage/rent)	Payment frequency (eg weekly)	Payment amount required	Payment applicable since (date)
1.
2.
3.

I declare that the expense(s) listed above are incurred by me on a recurring basis.

Note - Please remember it is your responsibility to notify Prosperity when this expense ceases to be incurred.
Part B

Expense reimbursement declaration*

TOTAL AMOUNT
Part C

EML Living Expenses
Please confirm the ff.

I am confirming that I wish to alter my packaging to an EML Living Expenses CardI have completed an EML Living Expenses Card Application
Employee Signature*

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Or upload e-signature

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Cancelof
Date
I declare that the above expenditure is in accordance with the requirements described in my employer’s salary packaging guide. I also declare the above expenditure was incurred by me and has not been previously reimbursed
by my employer or any other party.
Should be Empty:

Benefit Confirmation for Salary Packaging