NAT 74727-10.2017
Division 293 Tax –
refund or debt release
application for former
temporary residents
Instructions and application for individuals
Who should complete this application?
Under Subdivision 293-G of the Income Tax Assessment
Act1997, you can only apply for a refund of Division 293
payments if all of the following criteria apply:
you received a departing Australia superannuation
payment(DASP)
you paid all or part of your Division 293 tax liability
you applied for the refund in the approved form.
If you do not meet all the above criteria, you are
notentitled to a refund of tax under Division 293 of the
Income Tax Assessment Act 1997.
However, if you incurred a Division 293 tax liability during
your time in Australia, and you have not paid it, complete
this form and we will assess whether we can release
you from the liability. You will still need to have received
aDASPprior to making this application.
How to complete this application
Section A: Reason for application
Question 1
Why are you completing this form?
Select the reason you are completing this application.
Section B: Former temporary resident details
Question 2
Tax file number
Provide your tax file number (TFN). We are authorised under the
Taxation Administration Act 1953 to collect this TFN. You are
not required by law to provide the TFN, but it will help reduce
the risk of administrative errors that could delay the processing
of your application.
Question 3
Name
Provide your full name.
Question 4
Previous name
Provide details of any previous names, if applicable. You
need to provide certified evidence of their name change – for
example, a marriage certificate, deed poll or change of name
certificate from the Births, Deaths and Marriages registration
office in your country. These documents must be certified
copies. If there is insufficient space, write the details on a
separate page and include it with this form.
Question 5
Date of birth
Provide your date of birth.
Question 6
Current residential address
Provide your current residential address.
Question 7
Current postal address
Provide your current postal address.
If this is the same as the residential address, write ‘AS ABOVE’.
Question 8
Phone and mobile number
Provide your current phone number including your
countrycode.
Question 9
Email address
Provide your current email address.
Question 10
Last address in Australia
Provide your last Australian postal address.
Section C: Details of your visa and passport
Question 11
Passport and visa class
Provide the passport details that you used to enter Australia
as a temporary visa holder. Include the passport number, the
name of the issuing country on the passport and the visa
class number (do not include the visa class description) that
the account holder previously used to enter Australia as a
temporary visa holder.
Question 12
Date of arrival
Enter the date that you entered Australia.
Question 13
Date of departure
Enter the date that you departed Australia.
Section D: Departing Australia super payment
(DASP) details
Question 14
Have you received a DASP
To receive a refund or to be assessed for release from current
or future liabilities under Division 293 of the Income Tax
Assessment Act 1997, you must have received a DASP.
If you have not received a DASP then do not complete
thisform.
Question 15
Who did you receive your DASP from
A DASP can be received from either a super provider or from
money held with us. This information will help us verify the
information you are providing to support your application.
Ifyou have received a payment from both a super provider
andtheATO, select both options.
If you received your DASP from a super fund, provide the name
of the super fund that sent you the DASP, their ABN (found on
the DASP statement) and your member account number that
your DASP was made from.
Section E: Supporting documentation
You must provide a payment advice from your super fund/s or
the ATO to show you have been paid a DASP. You also need to
provide a certification of immigration status if you received one.
Certification of personal documents
You must have all copies of your original documents certified
byan authorised person. If the original document is not written
in English, there are extra steps detailed below.
The authorised person certifying your documents must sight
the original and certify on the copies that each page is a true
copy by writing or stamping on each page ‘certified true copy’
followed by:
their signature
their printed name
their qualifications (for example, ‘Justice of the Peace’)
the date.
2 Division 293 Tax – refund or debt release application for former temporary residents
In Australia, you can have copies of your documents
certifiedbya:
barrister
Commissioner for Declaration (Queensland only)
doctor
judge
Justice of the Peace
minister of religion who is authorised to celebrate marriages
police officer
bank, building society or credit union officer of at least
fiveyears service
sheriff’s officer
solicitor.
If the original document is not written in English, you must
provide a written translation that an authorised translation
service has certified as a true and correct copy. Authorised
translation services include:
an appropriate embassy
a professional translation service accredited by the National
Accreditation Authority for Translators and Interpreters Ltd
(NAATI).
You must then provide the certified copies of both the original
document and the written translation.
If you are outside Australia, you can have copies of your
documents certified by consular staff at an Australian:
Embassy
High Commission
Consulate.
If you are unable to reach an Australian Embassy, High
Commission or Consulate, your documents can be certified
bya:
notary public
Justice of the Peace
judge of the court
registrar or deputy registrar of a court.
Section F: Authorised person’s details
Question 16
Name
Complete the full name of the authorised person.
Question 17
What is your relationship to the former temporary
resident in Section B
If you are an authorised representative making this application,
then select the appropriate option from the list to describe your
relationship with the former temporary resident.
Section G: Authorised person’s supporting
documentation
You must provide certified copies of documents listed at this
question. This will support your authority to act on behalf of
theformer temporary resident.
Refer to section E of the instructions for information about
certifying copies.
Section H: Payment options
Select and complete payment option 1 to receive payment
viaan Australian financial institution.
Select option 2 to receive payment by cheque.
Section I: Declaration
You need to complete one of the following:
declaration by a former temporary resident
declaration for an authorised person
declaration for a deceased estate.
Read the declaration. If it is correct, print your full name then
sign and date the declaration.
Lodging your application
Keep a copy of this application for your records and send
the original, together with certified copies of your supporting
documents, to us at:
Australian Taxation Office
PO Box 3578
ALBURY NSW 2640
AUSTRALIA
Division 293 Tax – refund or debt release application for former temporary residents 3
© Australian Taxation Office for the
CommonwealthofAustralia, 2017
You are free to copy, adapt, modify, transmit and distribute this material as
youwish (but not in any way that suggests the ATO or the Commonwealth
endorses you or any of your services or products).
Published by
Australian Taxation Office
Canberra
October 2017
JS 38975
Our commitment to you
We are committed to providing you with accurate, consistent and clear
information to help you understand your rights and entitlements and meet
yourobligations.
If you follow our information in this publication and it turns out to be incorrect,
oritis misleading and you make a mistake as aresult, we must still apply the law
correctly. If that means you owe us money, we must ask you to pay it but we will
not charge you a penalty. Also, if you acted reasonably and in good faith we will
not charge you interest.
If you make an honest mistake in trying to follow our information in this publication
and you owe us money as a result, we will not charge you a penalty. However, we
will ask you to pay the money, and we may also charge you interest. If correcting
the mistake means we owe you money, we will pay it to you. We will also pay you
any interest you are entitled to.
If you feel that this publication does not fully cover your circumstances, or you
areunsure how it applies to you, you can seek further assistance from us.
We regularly revise our publications to take account of any changes to the law,
somake sure that you have the latest information. If you are unsure, you can
checkfor more recent information on our website at ato.gov.au or contact us.
This publication was current at October 2017.
Page 1
Sensitive (when completed)
NAT 74727-06.2017
Division 293 Tax – refund or debt release
application forformer temporary residents
WHEN COMPLETING THIS APPLICATION
n Print clearly in BLOCK LETTERS using a black pen.
n Place X in all applicable boxes.
n Questions with an asterisk (*) must be completed.
The form can also be completed electronically (it can be saved
to your computer). When you have completed the form you
must print it.
Do not use correction fluid or tape to make corrections. If you
make a mistake on the form, make your corrections electronically.
Section B: Former temporary resident details
You are not required by law to provide your TFN – however, quoting your TFN reduces the risk of administrative errors that
could delay the processing of your application.
2 Australian tax le number (TFN)
4 Previous name (if applicable)
Family name
First given name Other given names
Title: Mrs Miss Ms Other
Mr
Remember to include certified evidence of the name change with this form – for example, marriage certificate, deed poll
orchange of name certificate from the Births, Deaths and Marriage Registration Office or equivalent in your country.
Day Month Year
5* Date of birth
3* Name
Family name
First given name Other given names
Title: Mrs Miss Ms
Mr Other
Section A: Reason for application
1* Why are you completing this form?
To request a refund of a payment of Division 293 tax liability and release from this debt.
To request a release from my Division 293 tax liability.
You will still need to have received a DASP prior to making this application.
The Commissioner may release a former temporary resident from any current or future Division 293 tax liability if they
become entitled to a refund because they have made a payment against this liability or they would have been entitled to
arefund if they had made a payment towards their Division 293 liability.
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7* Current postal address
10* Last address in Australia
8* Phone numbers
Daytime phone number (including STD or ISD code) Mobile phone number (including ISD code)
9* Email address
Section C: Passport and visa
Day Month Year
13* Departure date from Australia
Day Month Year
12* Arrival date into Australia
11* Passport details and visa class number
Passport number
Country of issue
Visa class number
Country if other than Australia
Suburb/town Postcode
(Australia only)
State/territory
(Australia only)
Suburb/town PostcodeState/territory
6* Current residential address
Country if other than Australia
Suburb/town Postcode
(Australia only)
State/territory
(Australia only)
Page 3
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Section D: Departing Australia super payment (DASP) details
14* DASP received
Yes
If you answered ‘no’ to this question, you will not be entitled to a refund of tax paid or release
from any current or future liability under Division 293 of the Income Tax Assessment Act 1997.
No
Section E: Supporting documentation
your Certification of Immigration Status
Supporting documentation
Primary (this must
be provided)
a DASP payment advice received from your super fund/s or the ATO.
Secondary (if you have received one)
15* Who did you receive your DASP from?
and/or
ATO
Date of payment
Day Month Year
Provide the following details
Super provider
Day Month Year
Date of payment
Super fund ABN
Member account number with this super fund
Add letter reference number
Provide details of the super fund from which you have received a DASP. If you have received more
than one DASP payment then list these on a separate sheet of paper and attach to this application.
If you have provided a TAN here you do not need to complete Section G.
Super fund name
Have you been advised by us that you are entitled to a Division 293 refund or release?
Section F: Authorised person’s details
16 Name
Family name
First given name Other given names
Title: Mrs Miss Ms
Mr Other
17 Relationship to the person listed in Section B
Authorised personal representative
Beneficiary of the deceased estate
Tax Agent
TAN
Other
Provide details
Yes No
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Section G: Authorised person’s supporting documentation
Provide a certified copy of one of the following documents, except if you are acting for a public trustee or you are a tax agent.
birth certificate or birth extract
citizenship certificate issued by the Australian Government
citizenship certificate issued by the New Zealand Government
pension card issued by Centrelink that entitles you to financial benefits
current Australian drivers licence issued under state or territory law
current Australian passport
current overseas passport
You must attach certified copies of the documents listed below to prove your identity and authority to act on behalf of the
former temporary resident. Refer to section E of the instructions for information about certifying copies.
AND
Provide a certified copy of the following relevant documents to prove your authority to act on behalf of the account holder
n if the account holder is not deceased
Power of Attorney, notice of public trustee, notice of appointment of a representative, or other formal notice or
legaldocument
n if the account holder is deceased and you are the legal personal representative
a death certificate and 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 for the deceased
n if the account holder is deceased and you are a beneficiary
a death certificate and one of the following
binding death nomination letter from a super fund with the expiry date, or a letter from the super fund
confirming your entitlement as a beneficiary
probate and the will for the deceased
notice of public trustee signed on behalf of the account holder and the will for the deceased
letter of administration for the deceased
documentation of other potential beneficiaries and their relationship to the deceased
OR
OR
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Section H: Payment options
Disbursement methods for any refunds owing to you may include cheque or electronic funds transfer (EFT). A refund cheque will be
issued to your current postal address provided in your response to Question 7 if you do not provide EFT details for a current
Australian bank account.
EFT details required are:
n BSB number – this number has six digits (do not include spaces or hyphens)
n account number – this number has no more than nine digits (do not include spaces or hyphens)
n account name – as it appears on the bank account records up to 32 characters.
Option 1
Option 2
Electronic funds transfer (EFT)
We need your Australian financial institution details to pay your refund of a Division 293 tax liability, even if you
have provided them to us before. Write the BSB number and account number (do not include spaces or
hyphens) and account name below.
Payment by cheque to you
Payment will be sent to the current postal address identified in section B.
BSB number (must be six numbers) Account number
Account name
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Section I: Declaration
Privacy
The ATO is a government agency bound by the Privacy Act 1988 in terms of collection and handling of personal information
and tax file numbers (TFNs). For further information about privacy law notices please go to ato.gov.au/privacy
If authorised by law, we may share this information with other government agencies, including the Australian Securities &
Investments Commission (ASIC) and the Australian Prudential Regulation Authority (APRA).
Heavy penalties apply for giving false or misleading information.
Complete and sign the relevant declaration for this application.
Declaration by a former temporary resident
I declare all of the following:
n the information given on this application, including any attachments, is accurate and complete
n I authorise and direct the ATO to pay any refund as indicated in Section H.
Declaration for an authorised person
I declare all of the following:
n I am authorised to act on behalf of the former temporary resident for Division 293 tax
n the information given on this application, including any attachments, is accurate and complete
n I authorise and direct the ATO to pay any refund as indicated in Section H.
Declaration on behalf of a deceased estate
I declare all of the following:
n I am a person authorised to make this application on behalf of the deceased estate of the former temporary resident
n the information given on this application, including any attachments, is accurate and complete
n I authorise and direct the ATO to pay any refund as indicated in Section H.
Name
Signature
Date
Day Month Year
Name
Signature
Date
Day Month Year
Name
Signature
Date
Day Month Year
Lodging your form
Post it to:
Australian Taxation Office
PO Box 3578
ALBURY NSW 2640
AUSTRALIA
OR
OR
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