Request for electronic funds transfer
payment for FHSA providers
WHEN TO USE THIS FORM
Complete this form to have payments made direct to your
financial institution account by electronic funds transfer (EFT).
You must be listed as an authorised contact with us to
make changes or update details on behalf of the first home
saver account (FHSA) provider.
INSTRUCTIONS FOR COMPLETING THIS FORM
This form can be completed on screen. When complete, print,
sign and date the declaration at the end of the form.
If completing this form by hand:
n print clearly in BLOCK LETTERS using a black or dark blue
pen only
n place
n do
n do
X in ALL applicable boxes
not use correction fluid or covering stickers
not use pins or staples to attach documents.
Section A: Entity information
This section is compulsory.
1
What is the entity’s Australian business number (ABN) or tax file number (TFN)?
We are authorised by the Taxation Administration Act 1953 to request tax file numbers. You do not have to provide a TFN.
However, not providing a TFN may increase the risk of an administrative error and/or delay the processing of this form.
ABN
TFN
OR
2
What is the entity’s legal name?
This should be the name of the entity that appears on the Australian Business Register.
Section B: Financial account details
3
Do you want to update the entity’s financial institution account details to receive payments of
the FHSA government contribution by EFT?
No
You do not need to complete this form.
Yes
4
What are the entity’s financial institution account details to receive payments of FHSA monies by EFT?
Payments will only be paid directly into a recognised financial institution account located in Australia. Account details provided
must be held by the entity. Payment of FHSA monies will be made to the nominated bank account until notified otherwise.
BSB number (include all six numbers)
Account number
Full account name, for example, ABC Superannuation Fund.
Do not show the account type, such as cheque, savings, mortgage offset.
For information on the types of payments able to be made by EFT, go to ato.gov.au
JS 29190
Sensitive (when completed)
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Section C: Declaration – must be completed by an individual authorised by the entity
Completing this declaration
Before you complete this declaration, check that you have provided accurate and complete information. You should provide all
information requested on this declaration, including your name, position held, contact number and registered tax agent registration
number (if applicable) then sign and date the declaration. We may not be able to process your request if you do not provide this
information.
Privacy
The ATO is a government agency bound by the Privacy Act 1988 in terms of handling personal information and tax file
numbers (TFN).
We are authorised by the Taxation Administration Act 1953 to ask for the information requested on this form including
your member's TFN. We require this information to help us administer taxation and superannuation laws. We may give
this information to other government agencies. For further information about privacy go to ato.gov.au/privacy
Name of signatory
Position held
Business hours phone number
After hours phone number
Mobile phone number
Fax number
Email address of contact person (use BLOCK LETTERS)
If you are the nominated registered tax agent, provide your tax agent registration number.
I declare that:
n I am authorised to complete this form on behalf of the entity whose Australian business number or
tax file number appears on this form, and the information given on this form is accurate and complete.
n The information I have provided is true and correct.
We may impose penalties for giving false or misleading information. Only a person currently on our records as having
authority to make changes or update registration details on behalf of the entity can sign this declaration.
Signature
Date
Day
Print form
Month
Year
Reset form
Lodging your form
Make a copy of your form for your own records before you send it to:
Australian Taxation Office
PO Box 3575
ALBURY NSW 2640
Sensitive (when completed)
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