Fillable Form 1194: Certication of Immigration Status (Department of Home Affairs)

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Form 1194: Certication of Immigration Status (Department of Home Affairs)

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Country of origin: AUSTRALIA
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1194 (Design date 03/21) - Page 1© COMMONWEALTH OF AUSTRALIA, 0321
Certification of Immigration Status
Form
1194
Department of Home Affairs
About this form
Important – Please read this information carefully before you
complete this form.
This form can be used to request a Certification of Immigration
Status for the purposes of making a Departing Australia
Superannuation Payment (DASP) claim with the Australian Tax
Office (ATO).
Important information about claiming DASP
The DASP scheme is administered by the ATO and the eligibility
requirements are set out in the Superannuation Industry
(Supervision) Regulations 1994.
If you accumulated superannuation while in Australia as a holder
of a Temporary Resident visa, you are eligible to claim DASP if
you meet all of the following requirements:
• you have left Australia
• you were an eligible temporary resident
• your Temporary Resident visa has ceased to be in effect
(ie. all Temporary Resident visas have expired or been
cancelled)
• you are not an Australian citizen, New Zealand citizen or
Australian permanent resident.
If you are an Australian Citizen, an Australian Permanent Resident
or a New Zealand Citizen, you will generally not be eligible for
payment of your superannuation benefits until you have reached
retirement age.
Applications for DASP claims can either be lodged:
• online via the ATO to either your superannuation fund and/or
ATO (for ATO-held super), or
• by paper directly submitted to either your superannuation
fund or to the ATO (for ATO-held super). DASP claim forms
are available from the ATO website
www.ato.gov.au/departaustralia
DASP online is a free service provided by the ATO and includes
online verification of your immigration status to confirm that
your Temporary Resident visa has ceased to be in effect and that
you have left Australia.
If you choose to claim DASP using the ATO paper application
form which is to be lodged directly with your superannuation
fund, you will be required to provide evidence in support of that
application to confirm that your Temporary Resident visa is no
longer in effect and that you have left Australia.
Further information about eligibility and the ATO DASP online
and paper application processes, including the ATO DASP
application form, is available from the ATO website
www.ato.gov.au/departaustralia
or by writing to:
Australian Taxation Office
PO Box 3100
PENRITH NSW 2740
AUSTRALIA
Request for Certification of Immigration Status
If you intend to lodge a paper application for your DASP claim
with your superannuation fund and your superannuation
withdrawal benefit is AUD5,000 or more, your superannuation
fund requires you to provide a Certification of Immigration Status
from the Department as evidence that your Temporary Resident
visa has ceased to be in effect and that you have left Australia.
Each person who wishes to request a Certification of Immigration
Status must complete a separate form 1194.
There is a fee associated with each request for Certification of
Immigration Status (see Charges).
For paper lodged DASP applications where your superannuation
withdrawal benefit is less than AUD5,000 you can provide your
own evidence to your superannuation fund confirming that your
Temporary Resident visa is no longer in effect (ceased/cancelled)
and that you have left Australia. This evidence would generally
include either a copy of your visa grant notification letter or a
copy of your visa label or visa cancellation advice from the
Department as well as a copy of your passport showing that you
have left Australia.
Where to send this form
Return your completed form by email to
GCN.admin@homeaffairs.gov.au
Note: Do not send ATO DASP claim forms to the Department.
Send these directly to your superannuation fund and/or the ATO,
depending on where your funds are being held.
What happens after you have lodged this form?
When the request is finalised the Department will email the
Certification of Immigration Status directly to your nominated
superannuation fund(s) and will send a copy to you either by
email or post.
Note: The Department allows 21 days for a letter sent by post to
be received at an overseas address.
Charges
There is a fee associated with the request for Certification of
Immigration Status.
Payment must accompany your request for Certification of
Immigration Status and is not generally refunded if your request
is not successful.
Fees may be subject to adjustment at any time, with many
charges subject to adjustment on 1 July each year. This may
increase the cost of making a request for Certification of
Immigration Status.
To check the application charge, refer to the Department’s
website www.homeaffairs.gov.au
Method of payment
Make your payment electronically through the ‘My Payments’
section of ImmiAccount. Sign into, or create, your ImmiAccount
and select My Payments>Manage Payments>Pre-Pay Paper Service,
at www.homeaffairs.gov.au/immiaccount
If you are outside Australia and cannot pay online in ImmiAccount
check the Department’s website for alternative payment methods
for your location www.homeaffairs.gov.au/locations
1194 (Design date 03/21) - Page 2 © COMMONWEALTH OF AUSTRALIA, 0321
Integrity of the information you provide
The Department is committed to maintaining the integrity of the
visa and citizenship programs. Please be aware that if you provide
us with fraudulent documents or claims, this may result in
processing delays and possibly your request being denied.
Appointing an authorised recipient
To appoint an authorised recipient you should complete:
• Question 19 – Options for receiving written communications,
and
• form 956A Appointment or withdrawal of an authorised
recipient.
Note: Registered migration agents/legal practitioners/exempt
persons do not need to complete form 956A.
Form 956A is available from the Department’s website
www.homeaffairs.gov.au/allforms/
Appointing a migration agent/legal practitioner/exempt
person
To appoint a migration agent/legal practitioner/exempt person you
should complete:
• Question 19 – Options for receiving written communications,
and
• your migration agent/legal practitioner/exempt person should
complete form 956 Appointment of a registered migration
agent, legal practitioner or exempt person.
Form 956 is available from the Department’s website
www.homeaffairs.gov.au/allforms/
Consent to communicate electronically
The Department may use a range of means to communicate with
you. However, electronic means such as fax or email will only be
used if you indicate your agreement to receiving communication
in this way.
To process your application the Department may need to
communicate with you about sensitive information, for example,
health, police checks, financial viability and persona
relationships. Electronic communications, unless adequately
encrypted, are not secure and may be viewed by others or
interfered with. If you agree to the Department communicating
with you by electronic means, the details you provide will only be
used by the Department for the purpose for which you have
provided them, unless there is a legal obligation or necessity to
use them for another purpose, or you have consented to their
use for another purpose. They will not be added to any mailing
list without your consent.
The Australian Government accepts no responsibility for the
security or integrity of any information sent to the Department
over the internet or by other electronic means.
If you authorise another person to receive documents on your
behalf and they wish to be contacted electronically, their
signature is required on form 956 or 956A to indicate their
consent to this form of communication.
Note: Electronic communication is the fastest means of
communication available and the Department prefers to
communicate electronically because this results in faster
processing.
Please keep these information pages for your reference
Important information about privacy
The Privacy Act 1988 contains 13 Australian Privacy Principles
which regulate the way that the Department collects and handles
personal information. Information about how the Department
collects, uses and discloses personal information for its key
functions can be found in form 1442i Privacy notice. More
information about the Department’s general information handling
practices (including form 1442i) can be found in the Department’s
Privacy policy at https://www.homeaffairs.gov.au/access-and-
accountability/our-commitments/privacy
Home page www.homeaffairs.gov.au
1194 (Design date 03/21) - Page 3© COMMONWEALTH OF AUSTRALIA, 0321
Certification of Immigration Status
Form
1194
Department of Home Affairs
Please open this form using Adobe Acrobat Reader.
Either type (in English) in the fields provided or print this form
and complete it (in English) using a pen and BLOCK LETTERS.
Tick where applicable
3
Your details
1 Your full name
Family name
Given names
2 Your name as shown in your travel document on entry to Australia on the
Temporary Resident visa
(If the same as your present name, write ‘AS ABOVE’)
Family name
Given names
Reason for change:
Deed poll
Marriage
Other
Evidence of any name changes must be provided, eg. marriage certificate,
deed poll evidence, etc. (All documents MUST be certified copies)
3 Have you been known by any other names?
(including name at birth, previous married names, aliases)
No
Yes
Give details
Family name
Given names
Reason for change:
Deed poll
Marriage
Other
If you have been known by any names other than these names, please
provide documentary evidence. (All documents MUST be certified copies)
4 Sex Male
Female
Indeterminate /
Intersex / Unspecified
5 Date of birth
Day Month Year
6 Country of birth
7 Country of citizenship
8 Have you departed Australia?
No
Yes
9 Current address for correspondence
Postcode
10 Telephone numbers
Office hours
( ) ( )
Country code Area code Number
After hours
( ) ( )
11 Do you agree to the Department communicating with you by fax, email
or other electronic means?
No
Yes
Give details
Fax number
( ) ( )
Country code Area code Number
Email address
12 Details of entry to Australia on the Temporary Resident visa
Date of first arrival
Day Month Year
Place of arrival
Flight number/name
of ship (if known)
Passport number when
you arrived in Australia
13 Details of departure from Australia
Date of last departure
Day Month Year
Place of departure
Flight number/name
of ship (if known)
Passport number when
you departed Australia
1194 (Design date 03/21) - Page 4 © COMMONWEALTH OF AUSTRALIA, 0321
14 If you arrived as a child (under 18) and no longer hold the passport or
travel document you used on your first arrival, please give the following
details
Parent’s full name
Parent’s former name
(if applicable)
Parent’s date of birth
Day Month Year
Sex Male
Female
Indeterminate /
Intersex / Unspecified
Parent’s full name
Parent’s former name
(if applicable)
Parent’s date of birth
Day Month Year
Sex Male
Female
Indeterminate /
Intersex / Unspecified
15 Provide details of your superannuation fund(s)
(Fund details must be provided because Certifications of Immigration
Status will be sent electronically to individual funds)
1. Fund name
Fund address
Postcode
Fund email address
2. Fund name
Fund address
Postcode
Fund email address
If there are more than 2 funds, further details can be included in your
email to GCN.admin@homeaffairs.gov.au
Assistance with this form
16 Did you receive assistance in completing this form?
No
Go to Question 19
Yes
Please give details of the person who assisted you
Title: Mr Mrs Miss Ms Other
Family name
Given names
Address
Postcode
Telephone number or daytime contact
Office hours
( ) ( )
Country code Area code Number
Mobile/cell
17 Is the person a registered migration agent, Australian legal practitioner
or an exempt person?
No
Yes
Go to Question 19
18 Did you pay the person and/or give a gift for this assistance?
No
Yes
Options for receiving written
communications
19 All written communications about this application should be sent to:
(Tick one box only)
Myself
OR
Authorised
recipient
OR
You should complete form 956A Appointment
or withdrawal of an authorised recipient
Migration agent
OR
Legal
practitioner
OR
Exempt person
Your migration agent/legal practitioner/exempt
person should complete form 956 Appointment
of a registered migration agent, legal
practitioner or exempt person
1194 (Design date 03/21) - Page 5© COMMONWEALTH OF AUSTRALIA, 0321
Payment details
20 Make your payment electronically through the ‘My Payments’ section of
ImmiAccount. Sign into, or create, your ImmiAccount and select
My Payments>Manage Payments>Pre-Pay Paper Service, at
www.homeaffairs.gov.au/immiaccount
If you are outside Australia and cannot pay online in ImmiAccount check
the Department’s website for alternative payment methods for your
location www.homeaffairs.gov.au/locations
Payment receipt number from the ‘My Payments’ section of ImmiAccount
Attach a copy of your printed receipt.
Declaration
WARNING: Giving false or misleading information is a serious offence.
21 I declare that:
• the information I have supplied in this form is complete, truthful and
correct in every detail.
• I have read the information contained in form 1442i Privacy notice.
• I understand the Department may collect, use and disclose my
personal information (including biometric information and other
sensitive information) as outlined in form 1442i Privacy notice.
If applying for Certification of Immigration Status:
• I consent to the Department of Home Affairs sending a Certification
of Immigration Status containing my personal information, together
with attachments (if any), to the superannuation fund(s) nominated in
this form.
Your
signature
-
Date
Day Month Year
We strongly advise that you keep a copy of this form and all
attachments for your records.
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Form 1194: Certication of Immigration Status (Department of Home Affairs)

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Completed 17 January 2022

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