Instructions Print Clear

Regular Payments List Request

Complete the form using blue or black pen and print in clear CAPITAL LETTERS

This form gives a list of all your regular direct debits, direct credits and periodical payments made to and from your HSBC
account over the last 13 months. This is your ‘Regular Payments List’.
Please return the signed and completed form to your nearest HSBC branch or:
Email to: accountswitchinghsbc@hsbc.com.au
Mail to: HSBC Bank Australia Limited, GPO BOX 5302, Parramatta NSW 2150

1. MY/OUR PERSONAL DETAILS

ACCOUNT HOLDER 1 ACCOUNT HOLDER 2 (if applicable)
Customer name Customer name

Email address Email address

Contact phone number Contact phone number

2. AUTHORISATION FOR HSBC TO OBTAIN YOUR REGULAR PAYMENTS LIST

Please  to confirm the following:
• I/We consent to HSBC to prepare a Regular Payments List (i.e. a list of all the regular payments to and from the account(s)
detailed in Section 3).
• I/We understand that this ‘Regular Payments List’ contains my/our personal information.
• I/We consent to having my/our ‘Regular Payments List’ emailed to my/our nominated email account.

3. DETAILS OF ACCOUNT(S) HELD WITH HSBC BANK AUSTRALIA

Financial institution name
HSBC Bank Australia

BSB number Account number Account name(s)

3 4
3 4
3 4

Please  to confirm the following:

• I/We am/are authorised to operate the account(s) described above.
• The account(s) listed above are personal account(s) held in my/our name(s).

4. AUTHORISATION
I/We authorise HSBC to act in accordance with my/our instructions set out in this form.
I/We agree to HSBC sending Electronic Communication to my/our electronic equipment, electronic email address, and making
information available on HSBC's website as outlined under the relevant product terms and conditions under the ‘Electronic
Communications’. I/We have understood the implications of electing this method of communication.

ACCOUNT HOLDER 1 ACCOUNT HOLDER 2 (if applicable)

Signature Date Signature Date

On completion of this form, DD MM YY On completion of this form, DD MM YY

please print and sign by hand please print and sign by hand
Full name Full name

Office User FI Name Date sent

Use
Only DD MM YY
Issued by HSBC Bank Australia Limited ABN 48 006 434 162 AFSL 232595 HSBC2001 10/20