Professional Documents
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Payment of unclaimed
superannuation money
– third party
How to complete your Application for payment
of unclaimed superannuation money – third party.
NAT 71696-02.2014
HOW TO COMPLETE THIS FORM Generally, unclaimed super for a deceased estate is paid to
the account holder’s legal personal representative. It can only
Section A: Reason for application be paid to a beneficiary when their proof of entitlement can be
Question 1 substantiated, for example, if the account holder had a current
Why are you applying for payment of the and valid binding death nomination at the time of their death.
unclaimed super? We will work out entitlement to any unclaimed super after an
Select the reason why you are lodging the application for application is lodged and processed. The ability to make a
the unclaimed super on behalf of the account holder. claim is not proof of entitlement.
If you are applying for unclaimed super on behalf of a Section B: Account holder’s details
person with a terminal medical condition, you must provide The account holder is the person in whose name the
us with certified copies of medical certificates from two unclaimed super is held.
registered medical practitioners and they must certify that
the account holder suffers from an illness, or has an injury,
Question 3
that is likely to result in their death within 12 months. You Tax file number
can provide one medical certificate signed by both medical Provide the account holder’s tax file number (TFN).
practitioners, or you can provide two separate certificates. Question 4
One of the practitioners must be a specialist in the area
Current legal name
related to the illness or injury. In some circumstances the
Provide the account holder’s full current legal name.
amount will be tax free.
Question 5
If you are unsure how to answer this question, phone us for Previous names
assistance. Refer to ‘More information’ on these instructions Provide the account holder’s previous names, if applicable.
for our phone details. If the current legal name is different to the name on the member
account, you will need to provide certified evidence of the
Question 2 name change – for example, a marriage certificate, deed poll or
What authority do you have to apply for payment of change of name certificate from a births, deaths and marriages
unclaimed super? registration authority in your state/country. For more information
A person authorised to act on behalf of the account holder about certifying copies of documents, see section F.
includes:
■■ someone appointed to act on behalf of the account holder Question 6
■■ someone who holds a power of attorney to act for the Sex
account holder Indicate the sex of the account holder by selecting the
■■ a public trustee acting for the person. applicable box.
Provide details of the account holder’s current residency and ■■ justice of the peace
immigration status. If the account holder is deceased, select ■■ minister of religion who is authorised to celebrate marriages
their status as at the day they died. ■■ police officer
Where ‘Current temporary visa holder’ is selected, you must ■■ bank, building society or credit union officer with at least
is deceased
is a former temporary resident because they previously held a temporary visa that has ceased to be in effect (has expired or
been cancelled) for at least six months and, in respect of that visa, it has been at least six months since they left Australia
is a non-member spouse
has had super transferred to the ATO as a small or insoluble lost member account
has been diagnosed with a terminal medical condition and is not a former temporary resident
(refer to the instructions for information about the documentation you must supply).
If you are not sure which one of these applies to you, refer to page 2 of the instructions.
5 Previous names
If there is insufficient space, write details of your previous addresses on a separate page and include it with this form.
Title: Mr Mrs Miss Ms Other
Family name
Remember to provide certified evidence of the account holder’s name change (Australian marriage and change of name
certificates do not need to be certified).
7 Date of birth
8 Residential address
9 Postal address (if this is the same as residential address, write ‘as above’)
Address 2
Country of issue
Visa class
If the account holder is now an Australian citizen or a permanent Australian resident, you must answer question 14.
Otherwise go to section D: Account holder’s employer details.
14 Did the account holder leave Australia or hold a temporary visa after 30 June 2007?
No
Yes
When you have completed this question, go to section D: Account holder’s employer details.
Account balance $ .
, ,
Day Month Year Day Month Year
17 Proof of visa and passport details that the account holder used to enter and leave Australia as a
temporary visa holder
Only answer this question if you completed section C. Otherwise, go to question 18.
Provide a copy of both the following documents:
the account holder’s expired temporary visa
the account holder’s passport showing their photograph and identification pages and the
page showing their departure stamp from Australia if received.
If you completed question 17, you will only need to provide one more document from either of the lists below. If the account
holder is deceased, provide certified copies of the most recent documents the account holder held.
LIST 1
current Australian drivers licence issued under state or territory law
pensioner concession card issued by Centrelink that entitles the account holder to financial benefits
If the account holder has changed their name you must also provide certified evidence of the name change
(Australian marriage and change of name certificates do not need to be certified).
LIST 2
letter from Centrelink about a government assistance payment
notice issued by an Australian Government, state or territory authority within the past 12 months that contains
the account holder’s name and residential address – for example:
n an ATO notice of assessment
n a rates notice from local council
Australian bank, credit union or building society account statement, less than one year old, that shows the
account holder’s name and residential address and matches the current address details provided on this form
Medicare card
overseas drivers licence (the address listed on the licence must match the account holder’s current address
details provided on this form)
Marriage certificate
Any document you supply as evidence to verify the account holder’s change of name is not classified as a
second document. You must provide an additional proof of identity document.
Note: In some circumstances, we may need to contact you to request further evidence of proof of ownership to enable us to
process the claim, even where you have supplied the account holder’s TFN on this form.
If you have not quoted the account holder’s TFN or your application is for an amount more than $10,000, you must provide
a certified copy of one of the following documents:
correspondence from the account holder’s super fund (on the super fund’s letterhead) linking the account holder to the
account as the rightful owner or certifying that the account holder is the rightful owner
correspondence from the account holder’s employer (on the employer’s letterhead) who contributed super on the
account holder’s behalf, confirming the account holder’s employment and linking them with the super fund or
certifying that the account holder is the rightful owner of the super
a document (for example, a bank statement or utilities bill) linking the account holder to the last known address held by
their super fund.
If this application is for unclaimed super paid to us by more than one super fund, you must supply documentation to
prove the account holder is the rightful recipient for payment of each account more than $10,000.
21 Postal address
23 Email address
We are authorised under the Taxation Administration Act 1953 to collect this TFN. You are not required by law to
provide this TFN. However, quoting this TFN may reduce the amount of tax on this payment.
pensioner concession card issued by Centrelink that entitles you to financial benefits.
power of attorney
any other formal notice or legal document that states your authority to act on behalf of the account holder
n if the account holder is deceased and you are the legal personal representative:
a death certificate plus one of the following
probate, letters of administration or notice of public trustee signed on behalf of the account holder
documents proving that you are the legal personal representative of the deceased
notice of public trustee signed on behalf of the account holder and the will for the deceased
If you have changed your name you must also provide certified evidence of your name change (Australian marriage and
change of name certificates do not need to be certified).
Option 1
Electronic funds transfer (EFT)
We need the Australian financial institution details of the account holder or the authorised payee to pay any refund owing,
even if you have provided them to us before. Write the BSB number, account number and account name below.
Account name
Option 2
Payment by cheque to the account holder
Payments will be sent to the postal address provided in section B: Account holder’s details.
Option 3
Option 4
Remember to ask the account holder’s super fund if they will accept the amount, if fees or charges apply and for any
other information about how a payment may affect the account holder’s benefits, including death and disability insurance.
(Disclaimer: This information does not constitute financial advice. Should you need financial assistance, seek
professional advice.)
The tax law imposes heavy penalties for giving false or misleading information.
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