Participant Reimbursement Form

AgMove (Relocation Assistance - RATTUAJ)

Harvest Trail Services / Harvest Trail Information Service
* This form is to be used for external (non staff) payment requests related to AgMove (Relocation Assistance to Take Up A Job - RATTUAJ for Short Term Agricultural Work).
This form ONLY applies to Harvest Trail Services and Harvest Trail Information Service participants.

Complete this form in full and send to your MADEC Harvest Office or HTIS contact.
TO: MADEC AUSTRALIA
ABN: 48 086 804 015

PAYEE DETAILS
NAME: FAJAR PRASETYO
EMAIL: fajarpraseetyo@gmail.com
PAYEE BANK DETAILS
ACCOUNT NAME FAJAR PRASETYO
BSB NUMBER 062 028 ACCOUNT NUMBER 11976811
DECLARATIONS
I confirm that I have supplied the bank details and that the details provided are true and correct

I understand that if I supply incorrect bank details, I am responsible for recovery of the payment and any losses that may result
I have read the HTS / HTIS AgMove /RATTUAJ Reimbursement Request Fact Sheet and declare that my request for reimbursement only contains eligible expenses and that no one else has
claimed against the same receipts under the AgMove / RATTUAJ Program

WORK & TRAVEL INFORMATION

What date was your first day of harvest work? (DD/MM/YYYY) 14/12/2020
Has the harvest / agricultural work finished? Yes / No
If Yes, When did the work finish? (DD/MM/YYYY) 24/01/2021
If No, When do you expect the work to finish?
(DD/MM/YYYY)

Please write all travel dates from originating address to work location (DD/MM/YYYY, DD/MM/YYYY)
I have returned home to my regular residence. The travel dates of my trip home were: (DD/MM/YYYY, DD/MM/YYYY)
I have not returned home to my regular residence.

Would you like to claim $40 per day for each travel day above? Yes / No
(This flat rate is for food costs on agreed travel days. No receipts are required)

Did you travel via car and pay for the fuel to get there? Yes / No Please note: if you did not pay for the fuel, you cannot claim reimbursement for fuel.
I paid for fuel and have provided valid receipts for fuel purchases
I do not have receipts for fuel purchases, but declare that I incurred fuel costs whilst relocating for short term agricultural / harvest work

Are you requesting reimbursement of Accommodation costs of more than $250 per week? Yes / No
If YES, you must provide the following:
- 2 x quotes for comparable accommodation options in the area
- Proof of purchase as outlined in the AgMove (RATTUAJ) Participant Fact Sheet

If NO, please provide the above information or the following detail:

Name of Accommodation Supplier (example: Mildura Backpacker Hostel)
Tumbarumba Caravan Park
Address of Accommodation (example: 123 Blue St, MILDURA VIC 3500) Lauder St, Tumbarumba NSW 2653
Contact Name at Accommodation (example: John Smith)
Contact Phone number of Accommodation (example: 0400 000 000) 0437722697
Dates of stay - use inclusive dates (example: 05/11/2020 - 02/01/2021) 09/12/2020-16/01/2021
I confirm I stayed at the above accommodation for the dates of stay stated
 Participant Reimbursement Form - AgMove (Relocation Assistance - RATTUAJ) Page 2
The date I started Harvest/Agricultural work was 14/12/2020 (DD/ MM/ YYYY)

If the above date is on or before 04/05/2021, please answer the RATTUAJ questions If the above date is on or after 05/05/2021, please answer the AgMove questions

RATTUAJ OR AGMOVE

Have you completed at least 120 hours AND at least 6 weeks work? Yes / No How many hours of work have you completed? (minimum 40 hours)
Option: At least 120 hours over at least 6 weeks How many weeks of work have you completed? (minimum 2 weeks)
Options: At least 40 hours AND at least 2 weeks OR at least 120 hours AND at least 4 weeks
I have provided payslips outlining hours OR a piece rate payslip AND declaration of hours I have provided payslips outlining hours OR a piece rate payslip AND declaration of hours

EXPENSE DETAILS
AMOUNT $ INVOICE/ RECEIPT Internal Use Only
DATE TRANSACTION DETAILS
(GST INC) ATTACHED Yes/No Comments/ Notes
09/12/2020 The union Hotel 110 Yes
12/12/2020 Tumbarumba Caravan Park 140 Yes
19/12/2020 Tumbarumba Caravan Park 140 Yes
26/12/2020 Tumbarumba Caravan Park 140 Yes
02/01/2021 Tumbarumba Caravan Park 140 Yes
11/01/2021 Tumbarumba Caravan Park 140 Yes
16/01/2021 Tumbarumba Caravan Park 140 Yes

$950
Total requested $0.00
* Please note that MADEC is not authorised to complete this form on your behalf. Notes
* Reimbursements require supporting documentation as proof of payment (paid invoice, receipt) - please refer to HTS AgMove / RATTUAJ Participant Fact Sheet
* There are maximum limits to some items and maximum limits to the total amount reimbursable under AgMove (RATTUAJ) as per the AgMove RATTUAJ Participant Fact Sheet

Signed Costing Details

(internal use only)

Participant Name Fajar Prasetyo SITE

Date 8/06/2021 BU

HTS/F/18v5 HTS RATTUAJ – Participant Reimbursement Form Date of Issue: 08 June 2021 Page 1 of 1