Super/pension account Payment request

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1 Super/pension account Payment request Complete this form in BLOCK LETTERS and: post it to Asgard, PO Box 7490, Cloisters Square, Perth WA 6850 or fax it to (08) Note: if this form is faxed, you must also post the original. We only pay benefits when we receive the original form Questions? Call the Contact Centre on or Note: Privacy laws protect your privacy. Please read our Privacy Brochure for more information. A copy can be obtained from the Contact Centre. 1. Account details Withdrawals from term allocated pensions are only allowed in limited circumstances. Asgard will proceed with your payment request in circumstances where: your term allocated pension is not funded from the commutation of a complying pension or annuity and the withdrawal is made within six months of commencement of your term allocated pension; or your withdrawal is directly used to purchase another complying pension or annuity with comparable social security treatment. For example, this would include the purchase of another Asgard term allocated pension account. Account number Title Surname Given names Postal address Phone (business) Phone (home) State Postcode Phone (mobile) Facsimile Asgard super/pension payment request 1 of 6

2 2. Payment amount If you intend to claim a tax deduction for personal contributions made in the current or previous financial year, you must complete Section 8, Personal Tax Deduction Notice. If your Personal Tax Deduction Notice covers personal contributions included in your payment, you will be unable to vary the notice to reduce the amount claimed as a deduction after the payment has been made. Pay my entire benefit. We will close your account and cancel your insurance, unless you tell us to continue it. See section 7, Option to continue with insurance. (A continuation option is not available for Salary Continuance Insurance). Partial withdrawal Pay the following amount: Gross of tax (in words) Net of tax (in words) $,,. X X $,,. X X 3. Payment source (this option is not available for Elements, SMA Funds ACSS or ARS) Do you require funds to be taken from your share trading account? Yes No Is this partial withdrawal to be funded from a specific managed investment(s)? Yes Complete the section below. No Go to section 4, Payment options Product Code Managed investment name Gross amount $ Total Note: If there are insufficient funds in your nominated managed investment(s), Asgard will fund the balance of the withdrawal from your cash balance. If your withdrawal is more than 95% of the value of the nominated managed investment, this investment will be fully sold and the balance remaining once your withdrawal is paid will be placed in your cash balance to be invested according to your current PDS Part 2 - Investment selection. Dollar based partial payments will not change the accounts portfolio profile. If this is required, a separate Investment form must be submitted. 2 of 6 Asgard super/pension payment request

3 4. Payment options Please complete one of the following four options. Option 1: Transfer to another Asgard account i If you don t currently have an open account, complete and attach an application from a current Product Disclosure Statement or your financial adviser can open an account online for you. Account number (if known): * This account is not a superannuation fund. A transfer to this account will be treated as a cash withdrawal. If you haven t already supplied your tax file number to Asgard please complete the tax file number details in option 4 on the next page. Now go to section 6, Release of preserved benefits. Option 2: Rollover to another fund i If you are purchasing a pension, you need to have reached your preservation age (for a pre-retirement pension) or satisfy one of the conditions in section 6. Rollovers will come from preserved funds first, unless you give a different instruction. If your withdrawal is from a term allocated pension, is it being directly used to purchase another complying pension or annuity with comparable social security treatment? Yes No (Examples of complying pensions or annuities include lifetime pension or lifetime annuity, life expectancy pension or life expectancy annuity, and term allocated pension or term allocated annuity. Please note that ordinary allocated pensions do not meet this criterion.) Company name Fund name Fund ABN* Fund SFN* Fund SPIN* Postal address State Postcode Your destination member account number* Compliance letter # attached Yes No Now go to section 7, Option to continue with insurance. * Please contact the trustees of your new fund to obtain the SPIN, ABN, SFN and destination member account number. # We can t pay your benefit unless we have a compliance letter from your new fund. Contact the trustees of your new fund for a copy of this letter. Option 3: Rollover only my preserved benefit to the fund indicated in Option 1 or Option 2 and send the non-preserved benefit in cash. If you haven t already supplied your tax file number to Asgard please complete the tax file number details in Option 4 below. Now go to section 5, Cash forwarding details. Asgard super/pension payment request 3 of 6

4 4. Payment options (continued) Option 4: Cash withdrawal To be able to access preserved benefits, you need to satisfy one of the conditions in section 6. If you re not sure if you can get your benefits in cash, contact your financial adviser or the Contact Centre on My tax file number (TFN) is Under the Superannuation Industry (Supervision) Act 1993, your superannuation fund is authorised to collect your TFN, which will only be used for lawful purposes. These purposes may change in the future as a result of legislative change. The trustee of your superannuation fund may disclose your TFN to another superannuation provider, when your benefits are being transferred, unless you request the trustee of your superannuation fund in writing that your TFN not be disclosed to any other superannuation provider. It is not an offence not to quote your TFN. However giving your TFN to your superannuation fund will have the following advantages (which may not otherwise apply): your superannuation fund will be able to accept all types of contributions to your account/s; the tax on contributions to your superannuation account/s will not increase; other 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. Now go to section 5, Cash forwarding details. 5. Cash forwarding details Send the cheque to my postal address stated in section 1, account details. Note: Cheques are only made payable to you, the account holder. Credit the benefit to my financial institution account as detailed below. Financial institution name Note: Your name, as the account holder, must appear in the financial institutions account name. Branch Account name BSB number Account number Has a cash withdrawal previously been paid to the nominated account above? Yes You may fax this form to Investor Services on ( ). Your cash withdrawal will be paid to your nominated account above based on your faxed instructions. If you fax this form, please do not also post the original to Asgard Investor Services. If you fax this form and post the original also, your cash withdrawal may be processed twice. No You may fax this form to Investor Services on ( ). However, you must also post the original to Investor Services. Your cash withdrawal will be initiated based on your faxed instructions but your cash withdrawal will not be paid to your nominated account until the posted original is received by Investor Services. If you have any questions regarding the above, please contact the Contact Centre on of 6 Asgard super/pension payment request

5 6. Release of preserved benefits Tick the condition that applies to you. Retirement* I am over 55, I have ceased employment and do not intend ever again to work more than 10 hours per week. I am over 60 and I have ceased employment. I am over 65* Resignation from employer I have resigned from my employer who contributed to my account. This condition only applies to the release of restricted non-preserved benefits. For more information call the Contact Centre.* Permanent incapacity/disability i To access preserved benefits on the grounds of permanent incapacity, you need to provide certificates from two doctors stating that, in their opinion, because of your ill-health (whether physical or mental), it is unlikely that you can ever be gainfully employed in a capacity for which you are reasonably qualified because of education, experience or training. To enable us to classify your benefit payment as a disability superannuation benefit and calculate any applicable tax free component, in addition to the need for the certificates from two doctors, please: 1. Confirm that you are requesting payment of your benefits because you suffer from ill-health (whether physical or mental). Yes No 2. Advise the date on which you stopped being capable of being gainfully employed. (If you were employed, we would expect this date to be the date on which your employment terminated. Please note that, if you stopped being capable of being gainfully employed before you opened your account, we will not be able to classify your benefit payment as a disability superannuation benefit). 3. If you were employed at the time that you began to suffer from ill-health and your employment would have terminated when you reached a particular age or completed a particular period of service, please specify the date on you would reach the age or complete the period of service age (as the case may be). Date If no date is specified, the date on which you turn 65 will be used. Terminal medical condition i To access preserved benefits on the grounds of a terminal medical condition we require the following: (a) certificates from two registered medical practitioners certifying, jointly or separately, that you suffer from an illness, or have incurred an injury, that is likely to result in your death within a period (the certification period ) that ends not more than 12 months after the date of the certification; (b) at least one of the registered medical practitioners must be a specialist practising in an area related to the illness or injury suffered by you; and (c) for each of the certificates, the certification period must not have ended. Severe financial hardship (Special conditions apply, refer to your financial adviser or call the Contact Centre.)* * Payment request form cannot be used for financial hardship requests. Please contact your Adviser or the Contact Centre to obtain a Financial Hardship request form. Compassionate grounds (Special conditions apply, refer to your financial adviser or call the Contact Centre.)* * Please attach a letter from the Australian Prudential Regulation Authority (APRA) approving you can obtain access to your preserved benefits based on compassionate grounds. I was a temporary resident and have departed Australia; * Payment request forms cannot be used for Departing Australia payment requests. Please contact your Adviser or the Contact Centre to obtain a Departing Australia payment request form. I was a lost member and my entire benefit when released is less than $200. For more information call the Contact Centre.* * This condition is not available to persons who are not Australian or New Zealand citizens, or permanent residents. By signing this form, you declare that, where you have nominated this condition, you are an Australian or New Zealand citizen or permanent resident. Asgard super/pension payment request 5 of 6

6 7. Option to continue with insurance If you re closing your super account, and you have insurance, you can keep your insurance with Asgard at your current level of cover without providing further medical evidence. To take up this option, tick the box below, and we will send you the information and forms. I would like to continue my insurance. (A continuation option is not available for Salary Continuance Insurance). 8. Personal Tax Deduction Notice If your Personal Tax Deduction Notice covers personal contributions included in your payment you will be unable to vary the notice to reduce the amount claimed as a deduction after the payment has been made. We recommend that you talk to your financial adviser or tax professional regarding the amount you can claim as a tax deduction. I acknowledge personal contributions to my account as follows (complete all fields below including the financial year): $ $ $ will be claimed as a tax deduction under Subdivision 290-C of the Income Tax Assessment Act 1997 (and therefore subject to the 15% contributions tax), and will not be claimed as a tax deduction is the total amount of my personal contributions covered by this notice for the financial year ending 30 June At the time of completing this notice I confirm: that I have not lodged my income tax return for the year I am claiming this deduction; and the amount covered by this notice has not been included in an earlier notice. If you wish to claim a tax deduction for a prior financial year or vary a previous notice, please contact the Contact Centre or your financial adviser. 9. Signature I declare that the information in this form is true and correct. Signature Date Name (only required if someone other than the account holder has signed above) Adviser s phone 10. Supporting documentation Enclosed is the following supporting documentation. (Tick as necessary) Power of Attorney Guardianship KYC - Certified ID Change of name - Marriage Certificate/Birth Certificate Contribution Remittance Advice Additional Deposit Advice Court Orders Dealer stamp Asgard Capital Management Ltd ABN AFSL RSE Licence L , ACSS Fund ABN , ARS Fund ABN , Other Accounts Fund ABN Contact Centre PO Box 7490, Perth WA 6850 AS11009A-0310bt 6 of 6 Asgard super/pension payment request

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