PENSION
LUMP SUM WITHDRAWAL
APPLICATION
PLEASE COMPLETE AND SIGN THIS FORM AND RETURN TO:
BUSS(Q) GPO Box 2775, Brisbane Qld 4001
SECTION 1 MEMBERSHIP DETAILS
BUSS(Q) membership number
Date of birth (ddmmyyyy)
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Mr/Mrs/Ms/MissSurname
Given names
Postal Address
Street number / PO Box
Street name
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Suburb / Town / City
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Daytime contact number
Postcode
Mobile
Email
SECTION 2 AMOUNT OF WITHDRAWAL
(complete one only)
Please note that for withdrawals over $10,000, certified proof of identity must be provided (see the reverse side for details). I would like to
withdraw the following amount (minimum $1,000) from my account.
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An amount of
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The balance of my account
I would like the withdrawal to be made:
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From my current pension payment option, or
From
investment option.
SECTION 3 PAYMENT OPTIONS (tick one only)
I would like my lump sum paid as follows:
BA/424.3 02/16 ISS4
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Paid to the same bank account to which my pension is paid, or
Paid to a different account (see Section 4), or
Rolled over to an Approved Rollover Fund (please complete the Rollover details on the reverse side).
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BUSS(Queensland) Pty Ltd ABN 15 065 081 281 BUSSQ ABN 85 571 332 201 | AFS Licence 237860 | RSE L0002158 | Registration Number R1055870
CALL US 1800 PENSION (1800 736 746) | WEB www.bussq.com.au | EMAIL [email protected] | GPO Box 2775 Brisbane QLD 4001
SECTION 4 CHANGE OF BANK ACCOUNT DETAILS
Name of Bank, Building Society or Credit Union
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BSB number
Account number
Account name
I would like all my future pension payments paid to this account
SECTION 5 AGE DECLARATION
I declare that I am
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Over age 55 and permanently retired.
Over age 60 and have ceased employment.
Over age 65 (you may still be employed).
SECTION 6 ROLLOVER DETAILS
I would like this withdrawal rolled over to the following approved fund:
Specific name of new fund
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Cheque to be made payable to
Address of fund administrator (if known)
Street number / PO Box
Street name
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Suburb / Town / City
New fund membership number
State
Postcode
Superannuation Fund Number of New fund
Please note that any details you are unsure of can be obtained by contacting your new fund.
CERTIFIED PROOF OF IDENTITY
For withdrawals over $10,000, certified proof of identity must be provided. This can be a copy of your driver’s licence, current passport or
birth certificate. If this payment is to be made to an account other than the one to which your pension is paid, we require a copy of your
bank, building society or credit union statement or other document showing the account details. Persons able to certify your proof of identity
as a true copy of the original include a Justice of the Peace, solicitor, doctor, police officer, or bank manager.
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SECTION 7 RESIDENCY DECLARATION
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(your full name)
I,
BUSS(Q) Member number
Date of birth
of
(your address),
Declare that: (Please tick the box that applies to you)
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2.
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I am an Australian citizen, New Zealand citizen or permanent resident of Australia, or
I am a temporary* resident and one of the following applies:
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I have left Australia and I am NOT an Australian citizen, New Zealand citizen or permanent resident of Australia,
I hold a Subclass 405 (Investor Retirement) or Subclass 410 (Retirement) visa, or
I wish to claim payment on the grounds of permanent incapacity, temporary incapacity or terminal illness or this application
to withdraw super is on behalf of a deceased member – if any of these circumstances applies, please contact BUSS(Q) for
assistance.
*A
temporary resident is someone who holds a temporary visa as described in the Superannuation Industry (Supervision) Regulations 1994 or
in the Migration Act 1958.
Signature of applicant
Dated (ddmmyyyy)
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SECTION 8 AUTHORISATION
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I request a lump sum be paid as I have indicated on this form from my Retirement Pension account.
I am aware that before I rollover to a new fund I should obtain all relevant details of the BUSS(Q) fund, and I understand and acknowledge
the implications of transferring my benefits.
I accept the conditions set out in the Trust Deed and Rules of BUSS(Q) as amended from time to time.
I have read and understand BUSS(Q)’s Privacy Policy Statement contained in the Pension Choice Product Disclosure Statement.
I declare that I have fully read this form and that the information completed on this form is true and correct.
STOP
PLEASE SIGN AND DATE.
Forms without both a signature and date are unable to be processed.
SIGN
HERE
Signature of applicant
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Dated (ddmmyyyy)
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