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["REFUND REQUEST FORM"]
["Please email completed forms to: ",null,null,"claims@coallsl.com.au",null,null,null,null,null,null,null,null,null,null,null,null,"Full-time","January",2005,"Incorrect calculation of eligible wages"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Part-Time","February",2006,"Late notice of termination"]
[null,null,null,null,null,null,null,null,null,null,null,null,"Please complete one form for each month",null,null,null,"Casual","March",2007,"Late notice of leave without pay"]
["Employer Details",null,null,null,null,null,null,null,null,null,null,null," MONTH ",null,null,null,"Workers Comp","April",2008,"Late notice of Workers Comp"]
["Employer ID:",null,null,null,null,null,null,null,null,null,null,null,"YEAR ",null,null,null,null,"May",2009,"Not an eligible employee"]
["Company Name:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"June",2010,"Overpayment of levy"]
["Contact Name:",null,null,null,null,null,null,null,null,null,null,null,"Incorrect Amount Banked:",null,null,null,null,"July",2011,"Duplicate payment"]
["Contact No:",null,null,null,null,null,null,null,null,null,null,null,"Date Incorrect Amount Banked:",null,null,null,null,"August",2012,"Incorrect payment"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"September",2013,"Audit identified an error"]
["Authorised Officer",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"October",2014,"Other"]
["Name:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"November",2015]
["Position held:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"December",2016]
["Contact No:",null,null,null,false,null,null,null,null,null,null,null,null,null,null,null,null,null,2017]
[null,null,"I certify that the details shown below are correct.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2018]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2019]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2020]
["LSL Number","Surname","Given Name(s)","Date of Birth (dd/mm/yyyy) ","Work Status Full-time           Part-time       Casual or    Workers Comp","Hours Worked in month     (only Part-time or Casual work status)","Incorrect Eligible Wages","Incorrect Levy Paid","Correct Eligible Wages","Correct Levy to be Paid","Correct Hours Worked in month           (only Part-time or Casual work status)","Refund Amount","Reason for Refund"]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"H26-J26","v":0},null,null,{"$f":"LEFT(M26,4)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"H27-J27","v":0},null,null,{"$f":"LEFT(M27,4)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"H28-J28","v":0},null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,{"$f":"LEFT(M30,4)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"H44-J44","v":0},null,null,{"$f":"LEFT(M44,4)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,0,null,null,""]
[null,null,null,null,null,null,{"$f":"SUM(G26:G45)","v":0},{"$f":"SUM(H26:H45)","v":0},{"$f":"SUM(I26:I45)","v":0},{"$f":"SUM(J26:J45)","v":0},null,{"$f":"SUM(L26:L45)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,"TOTAL REFUND FOR ",{"$f":"CONCATENATE(N12,\" \",N13)","v":" "}]
["Please Note: ","All details requested above need to be provided to ensure that the request for refund can be processed."]
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["Privacy Statement "]
["Personal information collected by Coal LSL is protected by the Privacy Act 1988. Our Privacy Policy is available at www.coallsl.com.au and sets out the primary purposes for which Coal LSL collects, uses and discloses your personal information. Coal LSL will not use or disclose your personal information for other purposes unless you consent or it is permitted to do so by the Privacy Act 1988."]
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[null,null,null,null,null,null,null,null,null,"TRANS 34.2"]