Fillable Application for departing Australia superannuation payment (DASP) from (Australian Taxation Office)

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Application for departing Australia superannuation payment (DASP) from (Australian Taxation Office)

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The Application for departing Australia superannuation payment (DASP) from (Australian Taxation Office) form is 6 pages long and contains:

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Country of origin: AUSTRALIA
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Page 1
Sensitive (when completed)
NAT 7204-03.2018
WHEN COMPLETING THIS APPLICATION
n Print clearly in BLOCK LETTERS using a black or blue
penonly.
n Place
X
in all applicable boxes.
Remember to complete a separate application form for
each super fund that holds an account for you.
Lodge your application with your super fund, not with
the Australian Taxation Office (ATO) or Department of
Home Affairs.
Application for departing Australia
superannuation payment (DASP) from a
super fund or retirement savings account
Section A: Temporary resident’s details
1 Australiantaxlenumber(TFN)
2 Name
Title: Mr Mrs Miss Ms Other
Family name
First given name Other given name/s
6 Phoneandfaxnumbers
Office hours
(Country code) (Area code) (Phone number)
After hours
(Country code) (Area code) (Phone number)
Fax
(Country code) (Area code) (Fax number)
Title: Mr Mrs Miss Ms Other
Family name
First given name Other given name/s
If you have changed your name since you first entered Australia, include certified evidence of your name change
(forexample, your marriage certificate) with this form.
3 Previous name
If there is not enough space on this form, write the details on a separate page and include it with this application.
4 Dateofbirth
Day Month Year
8 Last address in Australia or address shown on your last superannuation fund statement
Suburb/town/locality PostcodeState/territory
7 Email address
5 Current postal address
Suburb/town/locality Postcode
(Australia only)
State/territory
(Australia only)
Country if outside Australia
Page 2
Sensitive (when completed)
Section B: Superannuation fund details
Provide details of the superannuation fund where contributions have been made by you or on your behalf. If you have more
than one superannuation fund, you must complete a separate application for each superannuation fund.
Your application cannot be processed if this section is incomplete.
9 Superannuation fund name
10 SuperannuationfundAustralianbusinessnumber(ABN)(if known)
11 Memberaccountnumber/swiththissuperannuationfund
Section C: Detailsofemployer/swhocontributedtotheaccount/s
If more than one employer contributed to the account/s, write all of the details on a separate page and include it with
thisapplication.
13 Employerbusinessname
12 EmployerAustralianbusinessnumber(ABN)(if known)
14 Employerbusinessaddress
Suburb/town/locality Postcode
(Australia only)
State/territory
(Australia only)
15 Period of employment
Day Month Year
to
Day Month Year
Page 3
Sensitive (when completed)
I have lodged a Certificate of Immigration Status and/or request to cancel a Temporary Resident visa (Form 1194)
with the Department of Home Affairs.
Section D: Supporting documentation and visa information for
temporary resident
Tick one of the boxes below to indicate what evidence of immigration status you are providing:
Note: this alternative option is only available if you are claiming a superannuation withdrawal benefit of less than $5,000AUD.
I have attached a certified copy of my visa, or evidence that I was the holder of a temporary resident visa which has ceased to
be in effect, and a certified copy of my passport showing my photograph, identification pages and departure stamps.
Note: If you have applied for a Certificate of Immigration Status from the Department of Home Affairs, you do not need to
provide visa information as they will provide this information to your super fund in the certificate.
List details for all visas you have held while working in Australia (including bridging visas), starting with subclass 417 or 462visa.
If you have held more visas while working in Australia, write the details on a separate page and include it with this
application.
The visa information you provide may be checked against information held by the Department of Home Affairs. Your
application may take longer if your information does not match information held by them.
If you have held either of the following two visas below, you need to provide visa information so we can accurately assess
yourapplication:
n Working holiday visa (subclass 417)
n Work and holiday visa (subclass 462).
Working holiday maker
Mark the boxes below if you are required to provide the following additional documentation:
Certified copies of documents to verify a name change from that listed on your passport/visa.
Additional information requested by your super fund.
OR
Visa subclass Visa type
Effective from Effective to
Day Month Year Day Month Year
e.g. Working holiday maker
e.g. 417
0 1
0 1
2 0 1 8
1 0
0 8
2 0 1 8
e.g. 010
e.g. Bridging visa
1 5
0 8
2 0 1 8
3 1
1 0
2 0 1 8
Page 4
Sensitive (when completed)
Section E: Payment options
Electronicfundstransfer(EFT)toanAustralianbankaccount
Account number
BSB code (Include all six numbers)
Full account name
Paymentwillbemadebychequetoyourcurrentpostaladdressprovidedatquestion5ontheclaimform.
International money transfer (IMT) to your financial institution overseas
Bank Code
Name and address of financial institution
Your address, exactly as it is registered with the overseas institution
Account name
Account number or International Bank Account Number (IBAN)
Currency you require payment to be made in
Please complete the section below to indicate your payment preference.
Note: Not all super funds make electronic transfers. As fees and charges (including currency conversion fees) may apply.
Youshould check with your fund to confirm the electronic payment method is available before making the request.
OR
OR
Page 5
Sensitive (when completed)
Section F: Declarationbytemporaryresident
Signature
Day Month Year
Date
Name (Print in BLOCK LETTERS)
You must sign this declaration before you send your completed application together with relevant certified copies
ofsupporting documentation to your super fund. You can only lodge this application after you leave Australia.
Do not send this application to the ATO or the Department of Home Affairs.
This section is to be completed by the temporary resident. It is not to be completed by an authorised representative.
Authorised representatives must complete section G of the form and read and sign the declaration at section H.
Read the declaration. If it is correct, print your full name then sign and date the declaration.
Declaration:
n I am the temporary resident named as the account holder of the specified superaccount/s
n the information given on this application, including any attachments, is accurate and complete.
Section G: Authorised representative details
Complete this section only if you have been authorised to claim DASP on behalf of the temporary resident named
insection A of this form.
You should contact the super fund to establish what evidence they require of your authority to make the claim on behalf
ofthe temporary resident.
You must also provide supporting documentation for the temporary resident you are claiming on behalf of, as explained
insection D of the Instructions.
Contact the super fund to confirm if they require any additional evidence in support of this claim.
16 Authorisation
In what capacity are you authorised to make this application?
17 Name
Title: Mr Mrs Miss Ms Other
Family name
First given name Other given name/s
Organisation name (if applicable)
18 Residentialaddress(orbusinessaddressifnotanindividual)
Suburb/town/locality Postcode
(Australia only)
State/territory
(Australia only)
Country if outside Australia
Page 6
Sensitive (when completed)
Section H: Declarationbyauthorisedrepresentative
This section is to be completed by an authorised representative making the DASP claim on behalf of a temporary resident.
Itisnot to be completed by the temporary resident.
Temporary residents making their own DASP claim must complete and sign the declaration at section F.
Read the declaration. If it is correct, print your full name then sign and date the declaration.
Declaration:
n I am authorised to make the claim on behalf of the temporary resident named as the account holder of the specified
superaccount/s
n the information given on this application, including any attachments, is accurate and complete.
Signature
Day Month Year
Date
Name (Print in BLOCK LETTERS)
Send the completed and signed application, together with certified copies of all relevant supporting documentation
tothesuper fund. Keep a copy of your application and certified documents for your records.
DonotsendthisapplicationtotheATOortheDepartmentofHomeAffairs.
21 Email address
19 Postaladdress(ifsameasabove–write‘asabove’)
Suburb/town/locality Postcode
(Australia only)
State/territory
(Australia only)
Country if outside Australia
20 Daytimephonenumber(includingcountrycodeandareacode)
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Application for departing Australia superannuation payment (DASP) from (Australian Taxation Office)

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Completed 17 January 2022

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