Please note: The release of superannuation benefits is subject to Government legislation and certain release conditions being met. As such, BUSSQ is required to meet the rules set down by this legislation. BUSSQ does not have the authority to waive any requirements listed on this form. age and You've reached preservation age plus 39 weeks, (see table in section 7), and preservation age Q230 letter from Centrelink, or complete section 8 Get the documents you need Q251 letter from Centrelink, or complete section 8
Partial payment of the home loan on your primary place of residence, to avoid foreclosure of the loan The purchase of disability aids for yourself or a dependent Call DHS on 1300 131 060 to find out if you are eligable to request the early release of your super beneifit from BUSSQ. You can apply for early release online via mygov. You will need a centrelink online acount. If you would prefer to use a paper application form or have any questions about mygov, please call the Department of Human Services. Certified proof of your identity. (see section 13) Proof of bank details (see section 9)
APPLICATION FOR BENEFIT Please complete and sign this form and return to: BUSSQ GPO Box 2775, Brisbane Qld 4001 BUSSQ membership number 1 YOUR PERSONAL DETAILS Mr/Mrs/Ms/Miss Given names Surname Street address Suburb / Town State Postcode Date of birth (dd/mm/yyyy) Daytime contact number Mobile BUSSQ uses your email address to provide important updates. We won t pass on your information to anyone and you can opt out of email communication at any time. Email 2 YOUR TAX FILE NUMBER (TFN) You don t have to provide your TFN and it s not an offence if you don t. If you do BUSSQ will only use it for purposes approved by law, including finding and identifying your super, calculating tax and providing information to the ATO. These purposes may change in the future. If you choose not to provide your TFN you may pay more tax on your benefits and contributions and you may not be able to make personal contributions to BUSSQ. These consequences may change in the future. Your TFN may be passed onto another superannuation fund if you transfer your benefits there and may be passed on to the ATO if required. Please advise us in writing if you do not want your TFN disclosed. I elect to provide my TFN and declare it is: Tax file number 3 CERTIFIED PROOF OF IDENTITY (please read Section 13) I have supplied certified proof of identity documentation. 4 PAYMENT TYPE (please read notes on page 5 and one option) SEVERE FINANCIAL HARDSHIP COMPASSIONATE GROUNDS Please proceed to Section 5 Please proceed to Section 9 5 I declare that I am unable to meet my reasonable and immediate family living expenses and that I do not have any assets (apart from my home) which could (reasonably and realistically speaking) be used or sold to cover this gap. I also declare that the amount I am requesting to be released is necessary to meet this reasonable and immediate family expense. I request the release of $ (please one option): Before tax After tax BUSS(Queensland) Pty Ltd ABN 15 065 081 281 BUSSQ ABN 85 571 332 201 AFS Licence 237860 RSE L0002158 Registration Number R1055870 CALL US 1800 MY BUSSQ (1800 692 877) WEB www.bussq.com.au EMAIL super@bussq.com.au GPO Box 2775 Brisbane QLD 4001 Page Page 1 of 16 of 4
6 CLAIMING UNDER CLAIM TYPE 1 Complete this section if you are claiming under Claim Type 1 (detailed on page 1 of the Info Sheet). Details of Income Please provide details of your fortnightly income (after-tax) Self Spouse TOTAL Commonwealth income Other benefits e.g. family support payments Other income allowance Number of dependents Details of Expenses Please provide details of your expenses and debts, after tax. These expenses should relate directly to you, your spouse and/or dependants, and should not include any business expenses. Copies of overdue bills or notices must be provided if listed below. These should not be more than three months old. Loan and credit card payments should be based on the minimum payments required, not the total amount owing. A. Debt(s) Minimum fortnightly repayment Arrears/overdue payment amounts Mortgage or other housing loan(s) Personal or car loan repayment(s) Credit card repayments Other (please specify) SUBTOTAL (A) B. Living expenses Estimated fortnightly amount Arrears/overdue payments amounts Food Rent or board Utilities e.g. gas, electricity, water Telephone Council rates Medical or dental Motor vehicle expenses e.g. fuel, registration, insurance Insurance premiums e.g. house, health, life Other (please specify) SUBTOTAL (B) TOTAL (A + B) 7 CLAIMING UNDER CLAIM TYPE 2 Complete this section if you meet the criteria under Claim Type 2 (detailed on page 1 of the Info Sheet). Preservation Age and Employment I declare that I have reached preservation age plus 39 weeks and at the date of this application, I am unemployed or employed for less than 10 hours per week. WHAT S MY PRESERVATION AGE? IF YOU WERE BORN YOU CAN ACCESS YOUR SUPER AT AGE Before 1 July 1960 1 July 1960 to 30 June 1961 1 July 1961 to 30 June 1962 1 July 1962 to 30 June 1963 1 July 1963 to 30 June 1964 1 July 1964 or after 55 56 57 58 59 60 Page 2 of 4
8 PERMISSION TO CONFIRM PAYMENTS ELECTRONICALLY I authorise: BUSSQ and/or Australian Administration Services Pty Ltd to use Centrelink Confirmation eservices to perform a Centrelink enquiry of my customer details. The Australian Government Department of Human Services (the department) to provide the results of that enquiry to BUSSQ and/or Australian Administration Services Pty Ltd. I understand that: The department will use information I have provided to BUSSQ and/or Australian Administration Services Pty Ltd to confirm my eligibility for early release of superannuation on the grounds of financial hardship based on whether I have been in receipt of a qualifying Centrelink payment for a specified period. The department will disclose to BUSSQ and/or Australian Administration Services Pty Ltd my personal information including my name, date of birth and payment status. Centrelink customer reference number (CRN) I give permission for an electronic confirmation OR I have supplied a Q230 or Q251 letter that is no more than 21 days old. 9 FINANCIAL INSTITUTION DETAILS Financial institution name Name in which account is held (must be your name or jointly in your name) BSB number Account number STOP Please attach a copy of a current bank statement confirming your name, BSB and account number to enable the benefit to be paid by electronic funds transfer (EFT). 10 RESIDENCY DECLARATION Temporary residents are not eligible to claim under Financial Hardship or Compassionate Grounds. For more information call us on 1800 MY BUSSQ (1800 692 877). Declare that: (Please tick the box that applies to you) I am an Australian citizen, New Zealand citizen or permanent resident of Australia, or I hold a Subclass 405 (Investor Retirement) or Subclass 410 (Retirement) visa. * A temporary resident is someone who holds a temporary visa as described in the Superannuation Industry (Supervision) Regulations 1994 or in the Migration Act 1958. 11 AUTHORISATION AND DECLARATION I authorise my superannuation benefit to be paid as instructed on this form. Upon payment of my full account balance from BUSSQ, I shall release BUSSQ from all claims, liabilities and obligation whatsoever in respect of my interest in BUSSQ. I understand that if my account closes as a result of this claim all insurance benefits will cease. I understand that fees, as outlined in the PDS, will be deducted. I understand that if I choose not to provide my Tax File Number (TFN) the Trustee is required to deduct tax from my benefit at the top marginal tax rate plus Medicare levy. I understand that any request to claim back tax paid to the ATO because of no TFN quoted needs to be done before claiming payment. I understand that tax may be deducted from my account. I understand that I cannot claim a tax deduction for personal superannuation contributions if this has not been processed prior to claiming my benefit. I understand that any contribution splitting must be done prior to claiming my benefit. By ticking the box above I have given consent for BUSSQ and/or Australian Administration Services to electronically confirm my Centrelink payment details I declare all information provided on this form is true and correct and that I meet the conditions outlined in the form and accompanying information. STOP PLEASE SIGN AND DATE. Forms without both a signature and date are unable to be processed. Signature of applicant SIGN HERE Dated (ddmmyyyy) BQ/APP/FIN/HRD 823.1 Page 11/16 3 ISS5 of 4
12 PRIVACY INFORMATION BUSSQ collects and uses your personal information in accordance with the BUSSQ Privacy Statement which is available from our website or by calling 1800 MY BUSSQ (1800 692 877). Please call us if you have any questions about your rights under the privacy legislation. 13 COMPLETING PROOF OF IDENTITY What identification can I use? Copies of the following documents may be used: EITHER One of the following documents only: A current driver s licence or permit issued under the law of a State or Territory, or Proof of Age Card - A card issued under a law of a State or Territory for the purpose of providing the person s age which contains a photograph of a person in whose name the documents is issued (includes Proof of Age Card or National Identity Card); or A passport issued by the Commonwealth, or a similar document issued for the purpose of international travel, or a national identity card. National Identity Card - That contains a photograph and the signature of the person in whose name the document is issued; and is issued by a foreign government, the United Nations or an agency of the United Nations - If it is in a language that is not understood by the person carrying out the verification it must be accompanied by an English translation prepared by an accredited translator. OR One of the following documents: Birth certificate or birth extract Citizenship certificate issued by the Commonwealth Pension card issued by Centrelink that entitles you to financial benefits. AND One of the following documents: Letter from Centrelink regarding a Government assistance payment Notice issued by Commonwealth, State or Territory Government within the past 12 months, containing your name and residential address. For example: - Tax Office Notice of Assessment - Rates notice from local council Certification of personal documents All copied pages of ORIGINAL proof of identification documents (including any linking documents) need to be certified as true copies by: A Justice of the Peace (JP) or Commissioner for Declarations (CDEC) A police officer A permanent employee of Australia Post with five or more years of continuous service A finance company officer with five or more years of continuous service (with one or more finance companies) An officer with, or authorised representative of, a holder of an Australian Financial Services Licence (AFSL), having five or more years continuous service with one or more licensees A notary public officer A registrar or deputy registrar of a court A person enrolled on the roll of a State or Territory Supreme Court or the High Court of Australia, as a legal practitioner An Australian consular officer or an Australian diplomatic officer A judge of a court A magistrate, or A Chief Executive Officer of a Commonwealth court. The person who is authorised to certify documents must sight the original and the copy and make sure both documents are identical, then make sure all pages have been certified as true copies by writing or stamping certified true copy followed by their: Signature Printed name Qualification (e.g. Justice of the Peace, Australia Post employee etc) Date, and Contact phone number. I certify this is a true copy of the original document. Julie Preston Justice of the Peace 19/06/2015 0412 345 678 Page 4 of 4 BQ/APP/FIN/HRD 823.1 11/16 ISS5