Estate or beneficiary of a deceased member

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1 ADF Cover Australian Defence Force Cover 07/16 Estate or beneficiary of a deceased member Benefit application form Who should use this form? This form may be completed by a person handling the estate or the legal personal representative where an ADF Cover member has passed away and there is no surviving eligible spouse or eligible child. Before you start Before completing this benefit application form, we advise you read the ADF Cover death benefits factsheet available from adfcover.gov.au Please ensure you attach all relevant documentation with this application. An incomplete application could result in a delay of your assessment or payment. Advice and information If you require further information or assistance completing this form, please call Your privacy is important to us Protecting your privacy is important to Commonwealth Superannuation Corporation (CSC). CSC collects personal information for the purposes of providing superannuation products and information to members, including the administration of superannuation legislation and rules, and for any other directly relatable purposes. Your personal information may be disclosed to Superannuation Administration Corporation, trading as Pillar Administration (Pillar) ABN , AFSL for the purposes of establishing, administering and releasing your account. CSC may also disclose your personal information to the extent that it is required or permitted to do so by law. A full copy of our privacy policy is available at adfcover.gov.au. Completing this application Following are some notes to assist you in completing each section of the benefit application. Section A About the deceased Please complete all boxes in this section. Section B About the person handling the estate The postal address you provide is where all correspondence will be sent. A contact phone number or address is also required in case we need to contact you regarding your application. This will help avoid delays in payment. Section C About the estate Please complete all boxes in this section. Section D About the beneficiaries Please complete all the boxes in this section Section E Payment details This section is where you nominate the account you want your benefit to be paid. We can only pay the benefit into an Australian bank account held in your name. If it s a joint account, one of the names listed must be yours. Please ensure the information here is correct, as a delayed payment may result if it is not. Any financial product advice in this document is general advice only and has been prepared without taking account of your personal objectives, financial situation or needs. Before acting on any such general advice, you should consider the appropriateness of the advice, having regard to your own objectives, financial situation or needs. You may wish to consult a licensed financial advisor. Commonwealth Superannuation Corporation (CSC) ABN: AFSL: RSEL: L Administrator of Australian Defence Force Cover (ADF Cover) ABN: of 10

2 Section F Attachments Please complete all the boxes in this section and provide any necessary certificated or statutory declarations as required. Section G Identification requirements To guard against fraud, money laundering, terrorism financing and to protect your benefit, we require you to provide us with enough identification to verify your identity before your benefit request can be processed. You are required to provide 100 points of identification. You can do this by choosing to have your documents verified electronically through our Document Verification System (DVS) or you can provide certified copies of your documents with your application. If you supply certified documents, the person certifying them must attest that the documents are true copies, and that you are the valid holder of the identification. Copies of your documents will be scanned and stored on our secure document management system. These electronic copies will be used only to confirm your identity. To further safe guard your privacy, any personal financial information should be blacked out on the copy that you send to us. Section H Declaration If you don t sign this section, your form will be returned to you and your payment may be delayed. Section I Lodgement Please send this form with your certified proof of identity documents (if applicable) to: CSC GPO Box 2252 Canberra ACT ed or faxed copies will not be accepted. 2 of 10

3 Section A About the deceased Service Navy Army RAAF ADF Cover membership number / Service number Salutation Mr Mrs Ms Miss Other Surname Date of death Please provide a copy of the death certificate Was the deceased legally married or in a relationship that was registered under a law of a State or Territory as a prescribed kind of relationship? Yes Do not use this form. Please refer to the ADF Cover Death benefits factsheet for instructions on the correct form to use. Did the deceased have any eligible children? Yes Do not use this form. Please refer to the ADF Cover Death benefits factsheet for instructions on the correct form to use. 3 of 10

4 Section B About the person handling the estate Salutation Mr Mrs Ms Miss Other Surname Postal address SUBURB STATE POSTCODE Residential address SUBURB STATE POSTCODE Contact number BUSINESS HOURS MOBILE NUMBER AFTER HOURS address Section C About the estate Did the deceased leave a Will: Is there a Grant of Probate or Letters of Administration: Will the Grant of Probate or Letters of Administration be obtained: Yes Please attach a copy Yes Please attach a copy Yes 4 of 10

5 Section D About the beneficiaries If there is more than one beneficiary, please attach the same details below for each additional beneficiary. Salutation Mr Mrs Ms Miss Other Surname of beneficiary of beneficiary Residential address SUBURB STATE POSTCODE I was dependent on the deceased Yes (If yes) Details of my dependency are as follows: Section E Payment details Please note that benefits can only be paid to an account in your name and must be in Australia. This can be a joint account. Name of institution Name of account holder(s) Must include your name Branch location Branch (BSB) number - Account number 5 of 10

6 Section F Attachments Please include any supporting information relevant to your claim, which may include A Death certificate (if available, if not, forward later) A Will A Probrate document Letters of Administration Certified copies of documents requested to prove your identitiy Other, please specify below For each beneficiary that was dependent on the deceased please also include: > > a statement, setting out the circumstances of the relationship > > utility and rates bills that support you lived with the deceased > > If you were not residing with the deceased a statement detailing the reason/s you were not residing with the deceased > > Evidence of dependence on the deceased, including financial statements, setting out the source of income and relevant expenditure Section G Identification requirements To protect your benefit against fraud, money laundering and terrorism financing, under the Anti-Money Laundering and Counter-Terrorism Financing Act 2006 you must prove your identity. To do this you will need to provide identification documents which total at least 100 points. Each document is valued at 70, 40 or 25 points. For example your birth certificate and driver licence total 110 points. You can elect to have these documents verified electronically by completing the section Verify my identity electronically. OR You can provide certified hard copy documents by completing the section Verify my identity using certified documents. An electronic copy of documents will be stored in a secure environment and hard copies will be securely stored off-site. All copies will only be used for the purposes of confirming your identity. Verify my identity electronically Your documents will be verified electronically using Document Verification Service (DVS), a national online system that allows approved government agencies and organisations to compare a member s identifying information with a government record. It is not a database and does not store any personal information. Requests to verify a document are encrypted and sent via a secure communications pathway to the document issuing authority for checking. I agree to the use of DVS to verify my documents You need to provide the requested details of documents (exactly as they appear on the documents) which total at least 100 points. For example your birth certificate and driver licence total 110 points. 70 points You can only provide the details of one document valued at 70 points. Australian Birth Certificate Registration State STATE Section G continued on next page 6 of 10

7 Registration Registration Date Date printed Certificate OR Australian Citizenship Certificate Stock Aquisition date OR Current Australian Passport Document Gender Male Female 40 points Australian Driver Licence or another licence or permit issued under a law of the Commonwealth, a state or territory Middle name Licence State of issue STATE Section G continued on next page 7 of 10

8 25 points You can provide the details of one document valued at 25 points and points will accumulate. Marriage Certificate or Change of Name Certificate Type of Certificate Marriage Change of Name (old) (old) Date of event (Date of Birth or Date of Marriage) Registration Spouse s Spouse s Registration State STATE Registration date Registration year Date printed Certificate Medicare Card Card Reference Card colour Green Blue Yellow Expiry date Verify my identity using certified documents te that if you have completed the section Verify my identity electronically, you do not need to complete this section and can go to Section E. I wish to verify my identity using certified documents Section G continued on next page 8 of 10

9 To protect your benefit against fraud, money laundering and terrorism financing, under the Anti-Money Laundering and Counter-Terrorism Financing Act 2006, you must complete a 100 point check and attach the following certified documents: Primary documents (70 points) Provide ONE of the following documents: > > Birth certificate > > Birth Card issued by the NSW Registry of Births, Deaths and Marriages > > Australian Citizenship certificate OR ONE of the following international travel documents: > > a current passport > > an expired passport which has not been cancelled and was current within the preceding two years > > another document of identity having the same characteristics as a passport (e.g. this may include some diplomatic documents and some documents issued to refugees). te: You do not accumulate additional points for more than one document from this category. Secondary documents (40 points) Provide ONE of the following documents containing your photograph and/or signature: > > an Australian driver licence or another licence or permit issued under a law of the Commonwealth, a State or Territory > > an identification card issued to a public employee > > an identification card issued by the Commonwealth, a State or Territory as evidence of your entitlement to a financial benefit > > a student ID issued by a tertiary education institution. te: Additional documents from this category can be awarded 25 points. Tertiary documents (25 points) Provide an identification document, e.g. marriage certificate (for maiden name only), credit card, council rates notice, telephone account, foreign driver licence, Medicare card, etc. te: More than one document may be counted, but points from a particular source may be counted only once, e.g. if a MasterCard and Visa card are issued from the same financial institution, only one may be counted. Certifying your documents The following people can certify your documents: > > a legal practitioner enrolled on the roll of a supreme court or the high court of Australia > > a judge or magistrate of a court > > a chief executive officer of a Commonwealth court > > a registrar or deputy registrar of a court > > a Justice of the Peace (JP) > > a notary public > > a police officer > > an Australian consular officer or an Australian diplomatic officer > > an agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public > > a finance company officer with five or more years of continuous service > > a member of the Institute of Chartered Accountants in Australia (ICAA), Certified Practicing Accountants (CPA Australia) or the Institute of Public Accountants (IPA). For a full list of certifying authorities, visit the Legislation website at legislation.gov.au The certifying authority must confirm in writing that you are the valid holder of the identification that you are presenting and that any copies are true copies of the original. Important The certification must include the signature, name, address, occupation, telephone number and registration number (if applicable) of the certifying authority. 9 of 10

10 Section H Declaration I declare that: > > the information I have provided is true and correct to the best of my knowledge. I acknowledge that it may be a criminal offence to knowingly provide false or misleading information on documents. > > I have read and understood the information in this form and in the scheme factsheet. > > I have filled in all sections applicable to me. > > I have checked my bank account details at Section E. > > I have provided relevant identification evidence as per Section F. SIGNATURE Date signed Section I Lodgement Please send this form with your certified proof of identity documents (if applicable) to: CSC GPO Box 2252 Canberra ACT 2601 Faxed and ed copies will not be accepted. END FORM phone post fax web adfcover.gov.au overseas callers ADF Cover GPO Box 2252 Canberra ACT 2601 (02) of 10

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