Permanent Emigration Withdrawal Form If you would like help in completing this form, please email kiwisaver@fisherfunds.co.nz or phone us on 0800 FF KIWI (0800 335 494) or +64 9 445 3377. You can complete this form on-screen by typing directly into each field. Once you have completed your details, please print, sign and post the form to Fisher Funds Management Limited, Private Bag 93502, Takapuna, Auckland 0740. Who should complete this form? Please use this form if you have permanently emigrated from New Zealand and you have lived overseas (excluding Australia) for at least 12 months. If you have permanently emigrated to Australia you cannot make a withdrawal on the grounds of permanent emigration. However you will be able to transfer all of your KiwiSaver funds to a participating Australian superannuation scheme (subject to a maximum transfer amount). Please contact your Australian superannuation scheme provider to obtain a transfer form. Checklist Please compete the checklist below and supply the relevant documents to support your request. Complete sections 1-2. Provide proof of bank account (refer to section 3 for our requirements). Provide certified proof of identity (refer to section 4 for approved identity documents and section 5 for how to certify those documents). Provide proof of address (refer to section 6 for our requirements). Provide proof of departure from New Zealand (refer to section 7 for our requirements). Confirm if you have ever been adjudicated bankrupt in section 8. Complete the statutory declaration in section 10 in front of a Justice of the Peace, Solicitor, Notary Public or other person authorised to take statutory declarations. You can find a Justice of the Peace near you by visiting the New Zealand s Justices Association website www.jpfed.org.nz or Yellow Pages www.yellow.co.nz. He/she will be able to certify your ID and witness your statutory declaration. You can also call Yellow s Directory Assistance on 018 (note charges up to about $1 apply). FF506-10/16 KIWISAVER SCHEME 1
Section 1: Your Details Title First Name/s Surname Date of Birth Fisher Funds KiwiSaver Scheme Account No. IRD Number City Country Postcode Home Phone Work Phone Mobile ( ) ( ) ( ) Email Section 2: Payment Details We will only make payments in New Zealand dollars to either a New Zealand bank account or an international bank account in your name. (The cost of an international transfer is paid by the member). We will adjust your withdrawal amount for any tax liability. Name of Bank Account Swift Code (if an overseas bank account) Account Number Bank Branch Account Number Suffix Name of Bank and Branch Section 3: Proof of your Bank Account Please provide proof of your bank account name and number by supplying any one of the following: a pre-coded deposit slip a copy of a cheque a copy of a bank statement an over-the-counter printed receipt with a tellers stamp an online bank account statement with the name of the bank in the header/footer 2 KIWISAVER SCHEME FF506-10/16
Section 4: Identity Documents Your application must be submitted with one of the identity document options set out in the table below. If these documents have been provided to us after 30 June 2013, they do not need to be provided again. 18 AND OVER - OPTION 1 18 AND OVER - OPTION 2 Passport* (pages containing name, date of birth, photograph and signature) New Zealand driver licence New Zealand firearms licence Full birth certificate* Certificate of citizenship PLUS one of the following: Overseas driver licence 18+ Card CHILDREN UNDER 16 CHILDREN AGED 16 AND 17 Full birth certificate* Passport* PLUS: Both parents/all guardian s identification (see option 1 or 2 above) Proof of guardianship (if applicable) Full birth certificate* Passport* PLUS: One parent/one guardian s identification (see option 1 or 2 above) Proof of guardianship (if applicable) *If you are supplying foreign identity documents you must also supply proof of New Zealand residency. Section 5: Certifying your Identity Documents Identity documents must be certified by one of the following people: Justice of the Peace Registered Teacher Notary Public Registered Solicitor Registered Doctor Member of Parliament Chartered Accountant Police Officer Identity documents cannot be certified by the following people: Yourself Someone related to you Your spouse or partner Someone who lives at the same address as you A person benefitting from this withdrawal The person certifying your documents must write the following statement on the copies of your documents: I certify this to be a true copy of the original document and confirm it represents the identity of (full name). The person certifying your documents must include the following details: Their name Their signature Their occupation The date of certification Certification must have been carried out within three months of your application. If you wish, you may personally bring your identity documents to the Fisher Funds office and we will copy and verify your documents. Please do not send in original versions of your identity documents. FF506-10/16 KIWISAVER SCHEME 3
Section 6: Proof of for all Persons 18 Years and Over Please provide proof of your physical address (not a PO Box) by sending us a copy of an invoice, statement, letter or contract in your name, dated within the last 12 months, from one of the following sources: utility providers e.g. water, electricity, gas, telecommunications professional service providers e.g. lawyer, accountant, doctor major service providers e.g. Sky TV, internet provider, newspaper, insurance central or local government correspondence e.g. IRD, benefit statement, rates notice current employer payslip bank correspondence or statement tenancy agreement Section 7: Proof of Departure from New Zealand Please provide evidence of confirmed travel arrangements, copy of passport pages showing departure date stamp or evidence of necessary visas. Date of depature Section 8: Bankruptcy Have you ever been adjudicated bankrupt or admitted to a No Asset procedure? Yes No (go to section 9) If Yes, please provide details: Date Official Assignee Reference/Case Number Section 9: Privacy Statement Any information that you provide to us may be used by Fisher Funds and the Supervisor and any of their respective related entities, and by other service providers to the Scheme to provide services in relation to your withdrawal request. I understand the information supplied by me with this application can be used to electronically verify my identity and address (where necessary) and may be disclosed for these purposes to third parties where relevant, including a government agency or reliable, independent source. You have the right to access the information held by us and you may also request that it be corrected. 4 KIWISAVER SCHEME FF506-10/16
Section 10: Statutory Declaration A Statutory Declaration is a written statement that allows a person to declare something to be true. This page will need to be completed in front of an authorised person who will witness the declaration. Who can witness me making the declaration? The following people can witness you making the declaration I, Notary Public Justice of the Peace Enrolled solicitor or barrister of the high court Name of Occupation solemnly and sincerely declare that: I am member of the Fisher Funds KiwiSaver Scheme. I am applying to withdraw or transfer my balance from the Fisher Funds KiwiSaver Scheme. I understand that any Member Tax Credit amounts will not be paid to me and will instead be repaid to Inland Revenue. I confirm that I permanently emigrated from New Zealand at least 12 months ago. I agree that by withdrawing from the Fisher Funds KiwiSaver Scheme I am ending my membership and all claims that have been made or may be made by me on the Manager and/or the Supervisor in relation to the Fisher Funds KiwiSaver Scheme. I understand that my withdrawal value will or might fluctuate based on the unit price(s) which applies when the withdrawal is processed and that fees, taxes and expenses may be deducted from my Fisher Funds KiwiSaver Scheme account. The information given in this form is true and correct. I acknowledge that the Manager and the Supervisor of the Fisher Funds KiwiSaver Scheme will rely on information provided in (or in connection with) this form and accordingly agree to indemnify them against any claims, liability, losses, damages, costs and expenses whatsoever which may arise directly or indirectly as a result of any information provided in (or in connection with) this form being untrue or misleading (including omission). I understand that the Manager and/or Supervisor of the Fisher Funds KiwiSaver Scheme will not be able to complete its assessment of this application if the information given in this form is incomplete or incorrect. I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957. Your Signature Declared at Date Before Me Name Signature FF506-10/16 KIWISAVER SCHEME 5