1 form Certification of Immigration Status and/or request to cancel a Temporary Resident visa 1194. About this form Request for cancellation of a Temporary Resident visa Important Please read this information carefully before you In order to claim a DASP either online with the ATO or by paper complete this form . with your superannuation fund, you may need to formally This form can be used to request a Certification of Immigration request the Department of Immigration and Border Protection Status and/or to request the cancellation of a Temporary (the department) to cancel your Temporary Resident visa. The Resident visa for the purposes of making a Departing australia visa cancellation can be requested if you are outside australia Superannuation Payment (DASP) claim with the Australian Tax and you do not intend to return to australia . Office (ATO). By completing this form you can formally request the department to cancel your visa, and those of your family Important information about claiming DASP members or any other person who holds a visa because you hold a visa.
2 The Departing australia Superannuation Payment scheme is administered by the Australian Taxation Office and the eligibility Please complete Parts A, C and D of this form if you are requirements are set out in the Superannuation Industry requesting the department to cancel a Temporary Resident visa. (Supervision) Regulations 1994. There is no fee associated with request for cancellation of a If you accumulated superannuation while in australia as a holder Temporary Resident visa. of a Temporary Resident visa, you are eligible to claim DASP if you meet all of the following requirements: Request for Certification of Immigration Status you have left australia ; If you intend to lodge a paper application for your DASP claim you were an eligible temporary resident; with your superannuation fund and your superannuation your Temporary Resident visa has ceased to be in effect withdrawal benefit is AUD5,000 or more, your superannuation (ie. all Temporary Resident visas have expired or been fund requires you to provide a Certification of Immigration cancelled); Status from the department as evidence that your Temporary you are not an Australian citizen, New Zealand citizen or Resident visa has ceased to be in effect and that you have left Australian permanent resident.
3 australia . If you are an Australian Citizen, an Australian Permanent Each person who wishes to request a Certification of Resident or a New Zealand Citizen, you will generally not be Immigration Status must complete a separate form . eligible for payment of your superannuation benefits until you There is a fee associated with the request for Certification of have reached retirement age. Immigration Status (see Charges). Applications for DASP claims can either be lodged: For paper lodged DASP applications where your superannuation online with the ATO; or withdrawal benefit is less than AUD5,000 you can provide your paper application submitted to your superannuation fund. own evidence to your superannuation fund confirming that your Temporary Resident visa is no longer in effect DASP online is a free service provided by the ATO and includes (ceased/cancelled) and that you have left australia . This online verification of your Immigration Status to confirm that evidence would generally include either a copy of your visa your Temporary Resident visa has ceased to be in effect and grant notification letter or a copy of your visa label or visa that you have left australia .
4 Cancellation advice from the department as well as a copy of If you choose to claim DASP using the ATO paper application your passport showing that you have left australia . form which is to be lodged directly with your superannuation Note: If you are using the free ATO online DASP service, your fund, you will be required to provide evidence in support of eligibility is verified online, confirming that your Temporary that application to confirm that your Temporary Resident visa Resident visa has ceased to be in effect and that you have left is no longer in effect and that you have left australia . australia . Further information about eligibility and the ATO DASP online and paper application processes including the ATO DASP Where to send this form application form is available from the ATO website You can send the completed form to the department by: email to or by writing to: post to: Australian Taxation Office Department of Immigration and Border Protection PO Box 3100 Superannuation Certification and Cancellation Team PENRITH NSW 2740 GPO Box 1496.
5 australia HOBART TAS 7001. fax to: +61 3 6281 9453. Note: ATO DASP claim forms sent to the department will be returned to the sender. COMMONWEALTH OF australia , 2015 1194 (Design date 10/15) - Page 1. What happens after you have lodged this form ? Integrity of the information you provide For visa cancellations when the request is finalised the The department is committed to maintaining the integrity of department will send you a letter either by email or post. the visa and citizenship programs. Please be aware that if you For Certification of Immigration Status requests when the provide us with fraudulent documents or claims, this may result request is finalised the department will email the Certification in processing delays and possibly your request being denied. of Immigration Status directly to your nominated superannuation fund(s) and will send a copy to you either by Consent to communicate electronically email or post. The department may use a range of means to communicate Note: The department allows 21 days for a letter sent by post with you.
6 However, electronic means such as fax or email will to be received at an overseas address. only be used if you indicate your agreement to receiving communication in this way. Charges To process your application the department may need to There is a fee associated with the request for Certification of communicate with you about sensitive information, for example, Immigration Status but there is no fee associated with the health, police checks, financial viability and personal request to cancel your Temporary Resident visa. relationships. Electronic communications, unless adequately encrypted, are not secure and may be viewed by others or Payment must accompany your request for Certification of interfered with. If you agree to the department communicating Immigration Status and is not generally refunded if your request with you by electronic means, the details you provide will only is not successful. be used by the department for the purpose for which you have Fees may be subject to adjustment at any time, with many provided them, unless there is a legal obligation or necessity to charges subject to adjustment on 1 July each year.
7 This may use them for another purpose, or you have consented to their increase the cost of making a request for Certification of use for another purpose. They will not be added to any mailing Immigration Status . list without your consent. To check the application charge, refer to the department's The Australian Government accepts no responsibility for the website or check with the nearest office security or integrity of any information sent to the department of the department. over the internet or by other electronic means. Method of payment Important information about privacy Your personal information is protected by law, including the In australia Privacy Act 1988. Important information about the collection, To make a payment, please pay by credit card, bank cheque or use and disclosure (to other agencies and third parties, money order (made payable in Australian dollars) to the including overseas entities) of your personal information, Department of Immigration and Border Protection.
8 Credit card including sensitive information, is contained in form 1442i is the preferred method of payment. Privacy notice. form 1442i is available from the department's website or offices of the Outside australia department. You should ensure that you read and understand Before making a payment outside australia , please check with form 1442i before completing this form . the Australian Government office where you intend to make the payment as to what methods of payment and currencies they can accept and to whom the payment should be made payable. Home page Send this form , together with the receipt of payment, to: General Telephone 131 881 during business hours Department of Immigration and Border Protection enquiry line in australia to speak to an operator (recorded Superannuation Certification and Cancellation Team information available outside these hours). GPO Box 1496 If you are outside australia , please contact HOBART TAS 7001. your nearest Australian mission. australia . Please keep these information pages for your reference 1194 (Design date 10/15) - Page 2 COMMONWEALTH OF australia , 2015.
9 form Certification of Immigration Status and/or request to cancel a Temporary Resident visa 1194. Please use a pen, and write neatly in English using BLOCK LETTERS. 4 Sex Male Female Tick where applicable . DAY MONTH YEAR. Part A Your details 5 Date of birth Part A must be completed by: 6 Country of birth the person requesting a Certification of Immigration Status (each person requesting Certification must complete a separate form ); or for visa cancellation only, the main visa holder. 7 Country of citizenship 1 Your full name 8 Have you departed australia ? Family name No Given names Yes 2 Your name as shown in your travel document on entry to australia on 9 Current address for correspondence the Temporary Resident visa (If the same as your present name, write AS ABOVE'). Family name POSTCODE. Given names 10 Telephone numbers Reason for change: COUNTRY CODE AREA CODE NUMBER. Deed poll Office hours ( ) ( ). Marriage After hours ( ) ( ). Other 11 Do you agree to the department communicating with you by fax, email Evidence of any name changes must be provided, eg.
10 Marriage certificate, or other electronic means? deed poll evidence, etc. (All documents MUST be certified copies). No 3 Have you been known by any other names? Yes Give details (including name at birth, previous married names, aliases) COUNTRY CODE AREA CODE NUMBER. No Fax number ( ) ( ). Yes Give details Email address Family name Given names 12 Are you using this form to request Certification of Immigration Status ? No Go to Part C. Reason for change: Yes Go to Part B. Deed poll Marriage Other If you have been known by any names other than these names, please provide documentary evidence. (All documents MUST be certified copies). COMMONWEALTH OF australia , 2015 1194 (Design date 10/15) - Page 3. Part B Request Certification of 2. Fund name Immigration Status 13 Details of entry to australia on the Temporary Resident visa Fund address DAY MONTH YEAR. Date of first arrival Place of arrival POSTCODE. Flight number/ Fund email address name of ship (if known). Passport number when you arrived in australia If there are more than 2 funds, attach a separate sheet.