Fillable superannuation money Application for payment of ATO-held (Australian Taxation Office)

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superannuation money Application for payment of ATO-held (Australian Taxation Office)

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The superannuation money Application for payment of ATO-held (Australian Taxation Office) form is 6 pages long and contains:

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Page 1
Sensitive (when completed)
NAT 74880-02.2019
Application for payment of ATO-held
superannuation money
COMPLETING YOUR APPLICATION
If you are filling in this form on screen:
n when completed, print form
n sign and date the declaration
n attach supporting documentation, if required
n obtain the declaration by two registered (legally qualified)
medical practitioners, at least one of whom is a specialist
practicing in an area related to the illness or injury suffered
bythe person
n ensure your name and tax file number are both written on
your supporting documentation
n mail your completed form to the address shown on page6.
You can submit your application online via myGov.
If submitting under Terminal medical condition / permanent
incapacity / permanent invalidity / disability, scan and attach
completed Section C Medical certification or
supportingdocumentation.
If you are filling in this form by hand:
n print clearly in BLOCK LETTERS using a black or dark blue
pen only
n place X in the applicable boxes
n sign and date the declaration at the end of the form
n attach supporting documentation, if required
n mail your completed form to the address shown on page6.
I have read the attached supporting information and conrm I am eligible to receive a direct payment
and have provided supporting documentation if required.
Section A: Authority
1 What authority do you have to apply for payment of super?
I am the account holder.
I am authorised to act on behalf of the account holder.
I am the legal personal representative of the account holder who is deceased.
For the purpose of this form ‘account holder’ means the person in whose name the super is held. ‘Third party applicant’
means the person applying for the payment of the super (the authorised person or beneficiary).
Section B: Account holder’s details
We are authorised by the Taxation Administration Act 1953 to request your tax file number (TFN). It is not an offence not to
quote your TFN but not providing it may lead to delays in processing your claim.
2 Tax le number
3 Name
Title: Mr Mrs Miss Ms Other
Family name
First given name Other given name/s
4 Date of birth
Day Month Year
Page 2
Sensitive (when completed)
5 Residential address
Suburb/town/locality State/territory
(Australia only)
Country if outside Australia
Postcode
(Australia only)
Suburb/town/locality State/territory
(Australia only)
Country if outside Australia
Postcode
(Australia only)
6 Postal address
8 Are you claiming under a terminal medical condition or permanent incapacity / permanent invalidity /
disability?
7 How can we contact you or leave a message if we need more information?
A contact number must be provided.
Email address
Daytime phone number
(Country code) (Area code) (Phone number)
After hours phone number
(Country code) (Area code) (Phone number)
Mobile phone number
(Country code) (Mobile number)
No
If you’re a ‘third party applicant’ – go to section D. If you’re the ‘account holder’ – go to section E.
Indicate the reason for application and complete section C: Medical certification.Yes
Reason for application
I am applying for my superannuation entitlements on the grounds of a terminal medical condition.
Ihave completed below or attached certification from two registered (legally qualified) medical practitioners,
atleast one of whom is a specialist practicing in an area related to my illness or injury, stating my condition
islikely to result in my death within 24 months.
OR
I am applying for my superannuation entitlements on the grounds of permanent incapacity / permanent
invalidity / disability (whichever is relevant).
I have completed below or attached certification from two registered (legally qualified) medical practitioners
stating my permanent incapacity / permanent invalidity / disability is likely to result in me being unable ever to
be employed in a capacity for which I am reasonably qualified through my education, training or experience.
Page 3
Sensitive (when completed)
Section C: Medical certication
MEDICAL PRACTITIONER 1
Registered (legally qualied) medical practitioner (terminal medical condition – specialist practicing
in an area related to the illness or injury suffered by the person) / registered (legally qualied) medical
practitioner (permanent incapacity / permanent invalidity / disability)
I certify that
is suffering from a terminal medical condition that is likely to result in the patient’s death within 24 months.
The date the patient was diagnosed with a terminal medical condition was
Day Month Year
OR
is suffering from a medical condition that is likely to result in the patient being unable to ever be employed in a capacity for
which he/she is reasonably qualified through education, training or experience.
The start date of the patient’s retirement due to permanent incapacity /
permanent invalidity / disability was
Day Month Year
Field of specialty
Australian Health Practitioner Regulation Agency (AHPRA) registration number
Name (Print in BLOCK LETTERS)
Signature
Date
Day Month Year
MEDICAL PRACTITIONER 2
Registered (legally qualied) medical practitioner (terminal medical condition) / registered (legally qualied)
medical practitioner (permanent incapacity / permanent invalidity / disability)
I certify that
is suffering from a medical condition that is likely to result in the patient being unable to ever be employed in a capacity for
which he/she is reasonably qualified through education, training or experience.
The start date of the patient’s retirement due to permanent incapacity /
permanent invalidity / disability was
Day Month Year
OR
is suffering from a terminal medical condition that is likely to result in the patient’s death within 24 months.
The date the patient was diagnosed with a terminal medical condition was
Day Month Year
Field of specialty
Australian Health Practitioner Regulation Agency (AHPRA) registration number
Name (Print in BLOCK LETTERS)
Signature
Date
Day Month Year
Page 4
Sensitive (when completed)
Section D: Third party applicant’s details
We are authorised by the Taxation Administration Act 1953 to request your tax file number (TFN). It is not an offence not to
quote your TFN but not providing it may lead to delays in processing your claim.
12 Tax le number
Provide your TFN if you are claiming as a beneciary
Name
Title: Mr Mrs Miss Ms Other
Family name
First given name Other given name(s)
11 Date of birth
Day Month Year
10 Organisation (if relevant)
9 Have you previously held a temporary visa?
No
If you’re a ‘third party applicant’ – go to section D. If you’re the ‘account holder’ – go to section E.
Go to section E: Payment details.Yes
Working Holiday Makers (WHM)
We will check your visa information with the Department of Home Affairs.
If you have held a Working Holiday visa subclass 417 or 462, your super may be taxed at the 65% rate.
For further information, visit our website at ato.gov.au/departaustralia
13 Residential address
Suburb/town/locality
State/territory
(Australia only)
Country if outside Australia
Postcode
(Australia only)
Suburb/town/locality State/territory
(Australia only)
Country if outside Australia
Postcode
(Australia only)
14 Postal address
Page 5
Sensitive (when completed)
15 How can we contact you if we need more information?
A contact number must be provided.
Email address
Daytime phone number
(Country code) (Area code) (Phone number)
After hours phone number
(Country code) (Area code) (Phone number)
Mobile phone number
(Country code) (Mobile number)
Section E: Payment details
If you are a former temporary resident, direct payment will be made to an Australian nancial institution account where the
ATO holds valid account details for you. Alternatively you can have the funds paid directly to another valid Australian nancial
institution, if you complete the details below.
If you do not have a valid Australian nancial institution account, payment will be made by cheque (in Australian dollars) to your
postal address provided at question 6 on this claim form.
If the account holder is deceased and you are the legal personal representative, payment will be made by cheque unless an
account has been specically set up for the deceased estate. The cheque will be made payable to the “Executor for <name of
the deceased person>”.
16 Electronic Funds transfer (EFT)
Provide your Australia nancial institution details to have your refund paid directly to you. It’s faster and simpler to have your
refund paid in this way. Complete the following details.
Account number (maximum of 9 digits)BSB number (must be 6 digits)
Full account name – for example, JQ Citizen. Do not show the account type, such as cheque, savings, mortgage offset.
Page 6
Sensitive (when completed)
OR
Section F: Declaration
Before you sign this form
Make sure you have answered all the relevant questions correctly and read the privacy statement below before you sign and
date this page. An incomplete form may delay processing and we may ask you to complete a new form.
Complete and sign one of the following statements that applies to you.
n I declare that the information given on this application is complete and correct.
n I authorise the ATO to verify my supporting documentation with the agency that issued the documents.
n I have read the supporting information and confirm I am eligible to receive a direct payment, and will provide supporting
documentation if required.
ACCOUNT HOLDER
Name (Print in BLOCK LETTERS)
Signature
Date
Day Month Year
I declare that:
n this application has been prepared in accordance with the information supplied to me by the individual or entity identified in
this application
n I have received a declaration from the individual or entity identified in this application stating the information provided is true
and correct
n I am authorised by the individual or entity identified in this application to submit this request to the Commissioner of Taxation.
n I have read the supporting information and confirm the individual or entity identified in this application is eligible to receive a
direct payment and I will provide supporting documentation if required.
n I authorise the ATO to verify any supporting documentation with the agency that issued the documents.
AUTHORISED PERSON / LEGAL PERSONAL REPRESENTATIVE
Lodging your application
Send your application to us at:
Australian Taxation Office
PO Box 3578
ALBURY NSW 2640
Name (Print in BLOCK LETTERS)
Signature
Date
Day Month Year
Penalties may be imposed for giving false or misleading information.
Privacy information
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
We may check the supporting documents you supply with the agencies that issued them.
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superannuation money Application for payment of ATO-held (Australian Taxation Office)

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Completed 9 September 2021

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