F.: HOSTPLUS Departing Australia Superannuation Payment (DASP) application. December 2019 Complete ths form if you are requesting a Hostplus baneft of more than $5,000 tobe paid, you wilaso need to apply ontine using the ATO online system at to.govauldepartaustralia, If your current account balance with Hostpls is less than $5,000 please apply using only the ATO online system at atogovauldepartaustala, Youmusthave entered Australia asa temporary resident andhave since departed Australia to quay for this typeof benefit. ‘Complete al felds marked with an asterisk *). Please use BLOCK letters inblack or blue pe. Pee 3/30 /3 (3/3 /4 [FIo} we | |oes PR me | Jor loere Dae ororor yn eS 0/7] (old) (Lisiais) [5)0/4) jaloja} (Ljoe Genera? PLALUI LIA eos Flolwitiolul Ral je VAL mlolul wis | ela Dstecemedenpiymentinkusrala” Oman trom Asta aj} Lola} lalolalal JS! loj3! 2{olai2) Yeu cre poner ovale Aut) wicrocrepandence west” sluaicielmal isitl Iniulimislel@ialsiel [slob [ted vog sto BELO! [wWlO/R TZ lol) TE state (M6 we SAA) 4D ORO cowery (BIQIAI Zt )L Telephone fcr cha country ed ner esos nce coty ote Bisisis ial ziaisiolale! slo FG) AI4) Lio} O14) FO O13) Plalulclal Fl cialmlolulmiziel i@iwiolrimiairie .iclolm!Funds can be electronically transferredto you [EFT)if you have an open Australian bank account. Please provide your bank detait {and proof of account, suchas a certified copy ofa bank statement to accept funds through EFT. Please note payments willbe madein SAUS. anciinteutonsnamet COMM MO LNW) EIALL! TM LBA lolol felelrizialplel tw Is sew ‘Slulalaly) [alpieicis Comey ATUL STTIRIA LL LIA Name of acenun Yor coi tn Smt plalulclal | Flolwl rlololrlal ol ela) folele) (aig lalaisiai AO1O19 15/38) 413i F Qj510) nial Vole lt lalvisttelalelsia i sete we NiS iw 2atlo CIA MLoj Ui via le |e isi Tivl DIE Lait] isiislolo| Ee Your privacy Hostpls has colected end may collect further personal _and sensitive information from you in order to assess and ‘determine your beneft application. This information's tkely ‘toinclude your name, address, date of birth, taxfile number, Visa details, nancial details and immigration details. We need tocollect the requested personal and sensitive information {rom you to assess and make a determination about your benef application. you do not provide us with the requested information, we may be unableto properly assess your benefit ‘pplication Your personal and sensitive information will only be ‘sclosed to Hostpls staffinvolvedin the assessment of your benefit application, or administrators Superpartners and/or curlegalor other professional advsorsif reasonably necessary “The Hostplis prvacy policy provides information about ‘overseas disclosure of personalinformation, how youmay ‘access and seek correction of your personalinformation as \wellas how youcan make a complaint about a breach of the ‘Australian Privacy Principles or the Privacy Act 1988. You ‘canaccess the Hostplus privacy policy at hostplus.com.2u/ privacy For all privacy related questions or privacy related ‘matters you can contact Hostplus on 1500 467875 or via email at privacy@hostplus.com.au ostpls usually discloses your personalinformation to our ‘administrator AAS, malhouses ard the ATO, AAS may disclose Slantur of aptcant” Vado Fortousn Damaumin yur personal information to overseas ncipionts Pleats see the 'AAS Privacy Policy at warwaae.com.aufor further information, Where you have provided personalinformation about third parties (people other than yourself. for example your beneficiaries) tis yourresponsibilty to inform these people that youhave provided Hostplus with their personal Information. You should refer them tothe Hestplus Privacy policy ‘authorise my Departing Austral Superannuation Payment, (DASP] tobe pala by Hostplus. + understand that when my fullbenefits paid, the fund shal be released from llclaims,labilties, and obligations inrespect of iy interestin the fund. + understand that upon cashing my chaque in my country of. residance| may incur fees and charges. + amaware that have the right to request any further Information that require in order to understand my benefit tentitlementsin the fund, inching any fees and costs that may apply tothe benefit withdrawal + understand thet myinsurence orcangements with Hostplus willcease from the date thet the benefits fully paid and my ‘count is closed, + I declare that tothe best of my knowedge a information given fon this form istrue and correct. lo ie} lol4} [alolala [fi]. Faxed or scanned forms cannot be processed. However photocopied forms canbe processed signed with an original signature [5 When you have completed this form plea sendit to: Hostplus, Locked Bag 5046, Parramatta NSW 2124