Complete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying super fund.

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1 Benefit access Gesb Super and West State Super SUP E R ANNUATION Complete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying super fund. Partial withdrawals and transfers Partial withdrawals or transfers must be for $1,000 or more. If you request a withdrawal or transfer from your account, you must maintain a minimum balance of $1,000 in your account. If you request a withdrawal or transfer which would reduce the balance below this amount, the request must be for the whole of the balance, which will close your account. How to complete this form 1. Read Appendix 1 Important information to check if you are eligible to access your super and for other important information. 2. If you intend to roll in money from other super funds before your benefit payment is finalised, complete a Super consolidation form for each required roll over, available at However, do not submit your Benefit access form until GESB has confirmed with you that all rolled-in monies have been received. 3. Fill in your details. Be aware that GESB may contact your employer to confirm details you provide in this form. 4. Please ensure you provide your tax file number (TFN) to allow us to authorise your request. You do not have to provide your TFN, however if you do not, you will have to provide certified copies of proof of identity documents to support the form instead. 5. See Appendix 2 Proof of identity to ensure you provide all required documentation with this form. 6. At Section 7, sign and date the form. Use the checklist to make sure you have provided all the necessary information. 7. Post your completed form and any supporting documents to: GESB PO Box J 755 Perth WA 6842 Transferring to gesb s allocated pension Do not use this form if you re transferring to GESB s allocated pension. Refer to our Retirement Income Allocated Pension Product Information Booklet and complete the application form. This includes GESB s Transition to Retirement option. Call your Member Services Centre on for more information. How long will it take? We aim to process your request within 20 working days after receiving your form and all necessary information. However, there are circumstances where it may take us longer to process your request. Section 1 Your details GESB member number WIN No. Office Use Only the fund that applies to this benefit access West State Super OR GESB Super Mr Mrs Miss Ms Other Surname (family name) Given name(s) Date of birth / / Male Female Residential address Postcode Postal address (if different from residential) address Telephone home ( ) ( ) Telephone mobile Tax file number Postcode Telephone work I do not wish my tax file number to be passed on to another superannuation fund. FOR OFFICE USE ONLY Note: GESB has a Privacy Statement to explain how it handles private information about individuals responsibly. Our Privacy Statement is available on our website or can be obtained by contacting your Member Services Centre. Government Employees Superannuation Board ABN

2 Section 2 Reason for benefit eligibility Section 5 Surcharge liability the statement that applies to you. If you are unsure which box to select, contact your Member Services Centre on as you must make a selection. I am not yet retired and want to roll over my benefit I am rolling over my benefit to another complying super fund and, if a full roll over has been requested, my employer has ceased making contributions to GESB I am purchasing a non-commutable income stream from another fund under Transition to Retirement (TTR) arrangements I am retiring and want to access or roll over my benefit I am aged years and have resigned from my current employer I have reached Commonwealth preservation age and have permanently retired and never intend to be gainfully employed for more than 10 hours a week (see Appendix 1, Section 5) I want to access a payment of my benefit I am aged 65 years or more My benefit is less than $200 and I have ceased employment with the employer who was contributing to my super GESB has approved early release of my preserved benefit due to permanent disablement or terminal illness. If you tick this box ensure you speak to GESB I am a temporary resident Before selecting this statement please contact GESB to discuss your options. I am a temporary resident permanently departing Australia Section 3 uk pension transfer Have you transferred a UK Pension to GESB? No go to Section 4 Yes if yes, have you lived in the UK since you transferred? Section 4 Yes contact GESB on No go to Section 4 Contribution splitting Do you intend to split eligible contributions to your spouse s super account before rolling over or transferring your benefit? No go to Section 5 Yes you will need to complete the Super contribution splitting application form available from or by calling your Member Services Centre on and attach it to this form when you return it to GESB Have you received a surcharge assessment notice from the Australian Taxation Office (ATO)? No go to Section 6 Yes read the important information section in Appendix 1, Section 8. Indicate if you want GESB to retain a portion before tax is deducted from your total benefit for the future payment of your surcharge liability Before-tax amount $ Section 6 Benefit payment options Complete one of these options to nominate how you want your benefit paid or rolled over. You can only be paid your super benefit if you meet a super condition of release. Option 1 Take a full or partial payment Complete this section to withdraw a full or partial payment. All payments must be made to the individual nominated in Section 1. 1a. Nominate the amount you wish to withdraw. Full benefit Before- Aftertax tax Partial benefit $ If you do not specify if your payment is to be before-tax or after-tax, your nominated amount will be reduced by any applicable tax. 1b. Nominate how you would like the benefit to be paid. Cheque Nominated personal bank account For security purposes, provide a copy of your bank statement showing your full name, the bank s name, BSB number and account number. If providing an internet bank statement, add your signature, printed name and date to the page. You must provide a copy of your bank statement, otherwise your payment will be made by cheque. Credit card, overseas, third party and business account payments are not allowed. Bank/Building Society or Credit Union name Branch address (suburb only) BSB number Account number Account name 2

3 Option 2 Roll over your benefit Complete this option if you want your benefit rolled over. If you are taking a partial payment and rolling the remaining balance over balance in the boxes below. Address of destination fund Postcode If you are rolling your benefit to a taxed GESB or external super scheme, your nominated partial benefit should be the amount prior to any applicable tax being deducted. Roll over to Complying super fund* - please complete option 2a or 2b below Full benefit Balance Partial benefit $ before-tax Existing West State Super account Full benefit Balance $ Partial benefit before-tax Unique Superannuation Identifier (USI) of destination fund Option 2b Roll over to your Self Managed Super Fund (SMSF) Complete this option if you want to roll over your benefit to a registered SMSF. You will need to provide GESB with certified proof of identity. Please read Appendix 2 to make sure your proof of identity documents will be accepted. ABN of SMSF Existing GESB Super account* Full benefit Balance $ Partial benefit before-tax Name of SMSF A new GESB Super account. By selecting this option you agree to the New GESB Super account conditions in Section 7* Full benefit Balance Partial benefit $ before-tax To roll over your benefit to more than one complying super fund, photocopy this part of the form and complete the information for each fund and include the amounts that you would like rolled over. Option 2a Roll over to an external complying fund Complete this option if you want your benefit rolled over to a complying super fund. If you have not provided your tax file number (see page 1), you will need to provide GESB with certified proof of identity. Please read Appendix 2 to make sure your proof of identity documents will be accepted. Membership number of destination fund Name of destination fund Membership number of SMSF Contact phone number of SMSF Nominate how you would like the benefit to be paid C h e q u e GESB will send your roll over cheque to the address registered with Super Fund Lookup. For more details visit Nominated SMSF bank account For security purposes, provide a copy of the SMSF bank account showing the name of the SMSF, the bank s name, BSB number and account number. If providing an internet bank statement, all this information is still required and in addition you need to add your signature, printed name and date to the page. You must provide a copy of the bank statement otherwise your payment will be made by cheque. Bank name Name of product/plan Telephone number of destination fund BSB number Account number Account name *Tax is applied at the receiving fund. 3

4 Section 7 Declaration and acknowledgement I declare that the information provided on all pages of this form and any accompanying material is true and correct I acknowledge that I may ask for any information that I reasonably require for the purpose of understanding the effects on my benefit entitlement prior to accessing my benefits. This includes information on fees, charges, effect on insurance cover (if applicable) and any other matter that I may require I declare that I require no such information, and request payment to be made in accordance with my instructions provided in this form and any accompanying material I am aware that a full withdrawal will cause my insurance cover (if any) to lapse unless I am purchasing a Transition to Retirement option I declare that I have read and understood Appendix 1 Important information If rolling over your full benefit to a new GESB Super account: You are only eligible to open a GESB Super account if you meet a reason for benefit eligibility in Section 2 and you agree to close your West State Super account You acknowledge that you have read the GESB Super Product Information Booklet available at and understand it contains general information only and does not take into account your investment objectives, financial situation or needs You understand your benefit will be invested in GESB Super s default investment plan (Balanced Growth plan). To change your investment plan use an Investment choice form, available at You acknowledge that your West State Super account will be closed and you will be unable to reopen a West State Super account By signing this form I agree to the declarations and acknowledgements in full. Your signature Date x / / Do you need to provide certified proof of identity? Yes, if you are: Withdrawing a lump sum Rolling over to a SMSF Rolling over to a complying super fund and have not provided a TFN Rolling over to a GESB Super or West State Super account No, if you are: Rolling over to a complying super fund (excluding SMSF) and have provided your TFN For details of certification requirements if you are overseas, please contact your Member Services Centre on our international number Checklist It is important that you complete all relevant sections and attach all the required documents. Your date of birth (Section 1) You must provide a copy of your bank statement otherwise your payment will be made by cheque (Section 6) Your TFN Original certified proof of identity documents (Appendix 2) if required (see above) Certified linking document if you have changed your name (Appendix 2) Any additional documentation to support your request If you are electing an alternative fund through choice ensure your employer has actioned your election prior to submitting this form All required sections have been completed If you require more information contact your Member Services Centre on Send your completed form and relevant documentation to: GESB PO Box J 755 Perth WA 6842 Penalties may apply if you make a false declaration. We will send you confirmation upon completion of your instructions. Note: GESB has a Privacy Statement that explains how GESB handles private information about individuals responsibly. Our Privacy Statement is available on our website or can be obtained by contacting your Member Services Centre on How to contact us T Member Services Centre F W gesb.com.au PO Box J 755, Perth WA 6842 Level 4 Central Park, 152 St Georges Terrace, Perth Government Employees Superannuation Board ABN /15 GESW0572

5 Important information Appendix 1 SUP E R ANNUATION Section 1 When you can access your super Section 4 Tax and your super benefit For most members, you ll be able to access your super once you ve reached the relevant Commonwealth preservation age and have permanently retired. Your super benefit may be paid out in the following circumstances: You permanently retire upon reaching your Commonwealth preservation age You ve reached Commonwealth preservation age but are under age 60, have permanently retired and never intend to be engaged in gainful employment for more than 10 hours a week You re aged 60 or over and have ceased a gainful employment arrangement You re aged 65 or over You die (in which case the benefit is paid to your estate) You become totally and permanently disabled Your super benefit is less than $200 and you have ceased employment with the employer who was contributing to the fund for you You receive approval to release your super on financial hardship or compassionate grounds You apply to access your super benefit to purchase a Transition to Retirement income stream, once you have reached Commonwealth preservation age but not yet permanently retired You re a temporary resident permanently departing Australia You re certified as having a terminal medical condition For more information about accessing your super refer to the relevant Product Information Booklet, available at Section 2 When you can roll over your super You can roll over your benefit to another complying super fund at any time. As GESB Super is a taxed scheme, tax is paid on contributions and income tax is paid on investment earnings. As West State Super is an untaxed scheme, any tax payable is applied to your benefit when it is paid to you as a lump-sum amount. If you roll your benefit over to GESB s Retirement Income Allocated Pension or another complying fund, tax may be payable on some or all of your benefit. The taxation treatment of super is complex and subject to change. So it s important you understand the impact tax will have upon your total benefit before making your final decision. You may wish to talk to your Member Services Centre for tax details that may apply to your benefit before completing this form. Section 5 Gainful employment Gainful employment means being employed or self employed for gain or reward in any business, trade, profession, vocation, calling, occupation, or employment. It does not include passive receipt of income. Section 6 Provision of information regarding your benefit Previous financial information relating to your member account was provided by GESB in good faith and was believed to be reliable and accurate at the time of preparation Your latest member statement or benefit estimate is based on current information obtained from your employer by GESB Benefit estimates may change if your employer provides different advice to GESB about your employment details GESB cannot be held responsible for any incorrect information provided by your employer If you believe any information provided to us by your employer may be incorrect it is important that you contact your employer or your Member Services Centre prior to completing this form. Section 3 Partial withdrawals and MY plan Section 7 Financial advice If you have chosen the MY plan investment option and you re requesting a partial benefit withdrawal, your benefit will be paid proportionally from each of the MY plan asset classes in which you are invested. The information contained in this form is of a general nature, and does not constitute legal, taxation or personal financial advice. In providing this information, GESB has not taken into account your investment objectives, financial situation or needs. GESB is not licensed to provide financial product advice. Before acting or relying on any of the information contained in this form, you should read the relevant Product Information Booklet available at and consider seeking professional financial and taxation advice to ascertain whether the information is appropriate for you. 5

6 Section 8 Surcharge liability Section 10 Providing your tax file number Before GESB can finalise payment in relation to your surcharge liability you must forward us a copy of the final assessment issued to you by the Australian Taxation Office (ATO). The ATO will generally send this to you shortly after you receive your benefit payment. When you receive your final ATO assessment, forward a copy to us and we will then issue a cheque to the ATO for this amount and to be sent to you. You will need to send this cheque to the ATO to settle your surcharge liability. We will forward to you any balance remaining from the withheld amount. To qualify for the surcharge assessment to be paid from your before-tax benefit, the amount must be paid from a pension account. Therefore eligible members will have their withheld amount transferred to a pension surcharge liability account, which will be closed upon final payment to the ATO. If you do not contact us to finalise your surcharge payment within two years of receiving your benefit, we will pay the withheld amount directly to you. Section 9 Disclaimer While every effort has been made to ensure the accuracy of information contained within this form, GESB makes no warranty as to the accuracy or completeness of this information, subject to any rights and terms implied by law. This form is not a substitute for the State Superannuation Regulations 2001, which govern the super schemes administered by GESB. Benefits can only be paid in accordance with the provisions of the State Superannuation Act and Regulations. To the extent permitted by law, GESB accepts no liability for loss or damage to any person, however caused (including negligence) which may be directly or indirectly suffered in connection with use of the information contained in this form. GESB reserves the right to change any of the information or representations contained in this form at any time without prior notice, subject to any legislative restrictions. Before providing us with your TFN please note: GESB is authorised to collect your TFN under the Superannuation Industry (Supervision) Act 1993, which will only be used for lawful purposes. These purposes may change in the future. GESB may disclose your TFN to other super funds, when your benefits are being transferred, unless you request in writing that we don t. It is not an offence for you not to provide GESB with your TFN. However giving your TFN to us will have the following advantages (which may not otherwise apply): We will be able to accept all types of contributions to your account(s); T he tax on contributions to your superannuation account(s) will not increase; O ther than the tax that may ordinarily apply, no additional tax will be deducted when you start drawing down your superannuation benefits; and It will make it much easier to trace different superannuation accounts in your name so that you receive all your superannuation benefits when you retire. Note: GESB has a Privacy Statement that explains how GESB handles private information about individuals responsibly. Our Privacy Statement is available on our website or can be obtained by contacting your Member Services Centre on How to contact us T Member Services Centre F W gesb.com.au PO Box J 755, Perth WA 6842 Level 4 Central Park, 152 St Georges Terrace, Perth Government Employees Superannuation Board ABN /15 GESW0572

7 Proof of identity Appendix 2 SUP E R ANNUATION If you are rolling over to a Self Managed Super Fund (SMSF) or withdrawing a lump sum, GESB is required to confirm your identity. You will need to provide documentation with each request to prove you are the person to whom the super entitlements belong. This information is not required if you have provided your tax file number (TFN) and are rolling over your benefit to a complying super fund. Section 1 Acceptable documents One document from List A OR one document EACH from List B and List C. List A List B Current Australian driver s licence with your photograph and signature or equivalent from a foreign country Current^ passport #, showing your name, date of birth, photograph and signature OR Birth certificate or birth extract # Citizenship certificate issued by the Commonwealth Pension card issued by Centrelink that entitles the person to financial benefits List C Notice issued by Commonwealth, State or Territory, no older than 12 months, that contains your name and residential address and records the provision of financial benefits under the law of the Commonwealth, State or Territory. For example, a letter from Centrelink Notice issued by the Australian Taxation Office (ATO), no older than 12 months, that contains your name and residential address and records a tax debt payable to or by you. For example, a Notice of Assessment from the ATO Notice issued by a local government body, no older than three months, that contains your name and residential address and records the provision of services to you. For example, a rates notice from your local council Section 2 Find someone to certify your documents The following people can certify copies of your original documents as true and correct copies: A permanent employee of Australia Post with five or more years of continuous service who is employed in an office supplying postal services to the public An officer with, or authorised representative of, a holder of an Australian Financial Services Licence (AFSL), having five or more years continuous service with one or more licensees A police officer A Justice of the Peace A judge of court A person enrolled on the roll of a State or Territory Supreme Court or the High Court of Australia, as a legal practitioner A notary public A registrar or deputy registrar of a court An Australian consular officer or an Australian diplomatic officer A magistrate A Chief Executive Officer of a Commonwealth court Information on how to certify your documents is provided on the next page. ^ The sole exception to the expired document rule is a passport. An expired passport is a valid identification document provided it has been expired for less than two years. # If your passport or birth certificate/extract is not in English, it must be accompanied by an English translation prepared by an accredited translator. If your passport is not an Australian passport it must include your signature. 7

8 Section 3 How to certify your documents All copied pages of original proof of identification documents (including any linking documents) need to be certified as true copies by any individual approved to do so. The authorising person must sight the original document and include the following details on the copies: 1. Stamp or write I certify this is a true copy of the original document on each page Followed by their: 2. Printed name 3. Signature 4. Qualification (eg Justice of the Peace), and 5. Date SAMPLE I certify this is a true copy of the original document. Julie Preston Justice of the Peace 08/08/2014 Change of name or signing on behalf of the applicant If you have changed your name or are signing on behalf of the applicant, you will need to provide a certified linking document. A linking document is a document that proves a relationship exists between two (or more) names. The following table contains information about suitable linking documents. Purpose Change of name Signed on behalf of the applicant Suitable linking document Marriage certificate, deed poll or change of name certificate from Births, Deaths and Marriages Registration Office Guardianship papers or Western Australian Enduring Power of Attorney If your Enduring Power of Attorney was made interstate or overseas you need to obtain an order from the Western Australian State Administration Tribunal to confirm your power of attorney can be used in Western Australia. If you require further information please contact your Member Service Centre on Note: GESB has a Privacy Statement that explains how GESB handles private information about individuals responsibly. Our Privacy Statement is available on our website or can be obtained by contacting your Member Services Centre on How to contact us T Member Services Centre F W gesb.com.au PO Box J 755, Perth WA 6842 Level 4 Central Park, 152 St Georges Terrace, Perth Government Employees Superannuation Board ABN /15 GESW0572

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