application for financial hardship - Hesta

1 Step 1 Member detailsComplete all details to help us identify your number (business hours): Telephone number (after hours): Telephone number (mobile): Email: Are you currently employed? Yes NoName of your current or last employer who contributed to Hesta :Date you left this employer:D D M M Y Y Y Y Is your spouse: Employed? Self-employed? Unemployed?We are authorised by law to ask for your Tax File Number (TFN). You do not have to provide it but if you don t, you may end up paying more tax than you need to. To find out more about how your TFN is used, disclosed or what may happen if you don t provide it go to our website My TFN is:My Centrelink Reference Number is: Age of financial dependants (dependants means anyone who is whole or in part financially dependent on you your spouse or children)Relationship Age Member name: Member number: Date of birth: D D M M Y Y Y Y Complete in pen using CAPITAL letters.

2 Faxed or scanned copies will not be accepted. Form must be completed in :A B C 1 2 2 XYou can apply for one payment of up to $10,000 gross (before tax) in a 12-month period if: (tick whichever applies) You ve received eligible Commonwealth Government income support payments for at least 26 continuous weeks, are currently receiving these payments, and you are unable to meet reasonable and immediate living can apply for any amount if: You ve reached your preservation age plus 39 weeks, received eligible Commonwealth Government income support payments for at least 39 cumulative weeks since reaching your preservation age and are currently either unemployed or employed for less than 10 hours a week.

3 You are not eligible to apply for a payment on financial hardship grounds if you are a temporary resident in financial dependantsEmployment detailsYour Tax File NumberYour Centrelink Reference Number (CRN)Are you eligible?Member detailsapplication for benefit payment financial hardshipPage 1 of 4 Step 2 Amount you are claimingHow would you like the benefit paid?Under superannuation laws the maximum amount which the Trustee may release is a single payment in any 12 month period, totalling $10,000 gross (before-tax) for persons under their preservation age. There is no maximum for persons over their preservation age plus 39 weeks. Full balance OR Requested amount before-tax (gross) or after-tax (net) (A minimum balance of $1,500 applies to all partial withdrawals) $.

4 Gross Net amount Provide your banking detailsAccount name: BSB: Account number: * If statement is not provided, account is not held at an Australian Banking Institution or is unreadable; we will issue you a (WEEKLY) financial ASSETSStep 3 Payment methodStep 4 financial assets, income and expenditureYour net incomeYour partner s net incomeYour dependant s net incomeAny other net income Total weekly incomeCash holdingsTerm depositsBank, building society and credit union accountsManaged investmentsListed shares and securitiesTotal financial assets$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$.

5 $ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,. $ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,. = $ ,. $ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,.$ ,. $ ,.INCOME (WEEKLY AFTER-TAX)Rent/BoardHome loan repaymentsPersonal loan repaymentsMinimum credit card repayments FoodElectricityGasTelephoneCar - Fuel/Servicing - Rego/CTP/Insurance - Loan/lease/rentalClothingCouncil, land and water ratesHouse insuranceEducation Health (medical and dental)Other weekly expenses (please specify) Total weekly expensesSURPLUS / SHORTFALL (WEEKLY)Income less expenses Other expenses (immediately due and payable) Page 2 of 4 Attach a current bank statement*The Trustee of Hesta must be satisfied that you have been receiving eligible Australian Commonwealth Income Support Payments for a continuous period of 26 weeks if aged under preservation age or, 39 cumulative weeks after reaching preservation age plus 39 weeks.

6 Note: To determine this, you will either need to complete the Centerlink Reference Number (CRN) Declaration below, or you can supply an original Centrelink letter (no older than 21 days) for Hesta to proceed with your declarationI authorise the Fund s Administrator, Australian Administration Services Pty Limited ('AAS') to use Centrelink Confirmation eServices to perform a Centrelink enquiry of my customer details and the Australian Government Department of Human Services ('DHS') to provide the results of that enquiry to AAS. I understand that DHS will disclose information to AAS based on whether I have been in receipt of a qualifying Centrelink payment for a specified period to confirm my eligibility for early release of superannuation on the grounds of financial hardship .

7 DHS will disclose to AAS my personal information including my name, date of birth and payment status. This consent, once signed, remains valid while I am a customer of Hesta unless I withdraw it by contacting Hesta or DHS. I can get proof of my circumstances/details from the department and provide it to Hesta so that my eligibility for early release of superannuation on the grounds of financial hardship can be determined. If I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be eligible to lodge a claim with signature: Date signed: D D M M Y Y Y YYou must complete the below Statutory declaration.

8 The Statutory declaration must be signed and witnessed by an authorised person. See certifying your identification at or see the Who can certify my identification section on the following Certifying your identification form for a list of persons who may witness the signing of a Statutory Declaration (Statutory Declarations Act 1959)I, NAME, OCCUPATIONof RESIDENTIAL ADDRESS make the following declaration under the Statutory Declarations Act 1959:1. The information provided on this form is correct. The amount I am requesting is necessary to meet my reasonable and immediate living expenses. I confirm that I do not have any assets I could reasonably sell to meet immediate financial needs.

9 These assets could include cash holdings, term deposits, bank, building society and credit union accounts, managed investments, listed shares and securities or any other similar I have read the Privacy Collection Statement and I understand how the Trustee of Hesta will use my personal I authorise my benefit to be paid by Hesta as instructed on this form. I am aware that I have the right to request more information if required to understand my benefit entitlements in Hesta , including any fees and charges that may apply to the benefit I understand that if my full account balance in Hesta is paid, the Trustee of Hesta shall be released from all claims.

10 Liabilities and obligations in respect of my interest in I understand that any insurance arrangements with the Trustee of Hesta will cease from the date my full account balance is paid or if and when there are insufficient funds in my account to pay the insurance I understand that I can only receive one benefit payment in a 12 month period (from any Fund) released due to severe financial understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every making this declaration:Signature: declared at PLACE on D D of M M Y Y Y YBefore me: Signature: Name of signatory:Qualification of Signature: Contact address of signatory:Step 5 Income support requirementsReturn this form together with the supporting documents and certified identification to.