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Rollover Request Form - OnePath

Rollover Request form OneCare Super April 2019. OnePath Custodians Pty Limited ( OnePath Custodians). ABN 12 008 508 496 AFSL 238346 RSE L0000673. OnePath Life Limited ( OnePath Life). ABN 33 009 657 176 AFSL 238341. Customer Services Retirement Portfolio Service (Fund) Phone 133 667. ABN 61 808 189 263 RSE R1000986 SFN 4571 159 75 Email 347 Kent Street, Sydney NSW 2000 Website Instructions Please forward this form to your existing financial institution to transfer funds from a non- OnePath superannuation or Rollover fund to the Retirement Portfolio Service. You may be requested by your existing fund to forward details or sign additional documents.

1 of 2 Rollover Request Form OneCare Super April 2019 OnePath Custodians Pty Limited (OnePath Custodians) ABN 12 008 508 496 AFSL 238346 RSE L0000673 OnePath Life Limited (OnePath Life)

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Transcription of Rollover Request Form - OnePath

1 Rollover Request form OneCare Super April 2019. OnePath Custodians Pty Limited ( OnePath Custodians). ABN 12 008 508 496 AFSL 238346 RSE L0000673. OnePath Life Limited ( OnePath Life). ABN 33 009 657 176 AFSL 238341. Customer Services Retirement Portfolio Service (Fund) Phone 133 667. ABN 61 808 189 263 RSE R1000986 SFN 4571 159 75 Email 347 Kent Street, Sydney NSW 2000 Website Instructions Please forward this form to your existing financial institution to transfer funds from a non- OnePath superannuation or Rollover fund to the Retirement Portfolio Service. You may be requested by your existing fund to forward details or sign additional documents.

2 Please action this as soon as possible. Please be aware that other financial institutions may impose a fee when you withdraw from their fund. There may also be delays in having your money transferred from your existing fund. To prevent delays in your Rollover , please ensure all details are completed and attach your most recent statement from your existing fund as well as proof of identity (see section 2). Important information: If you intend to lodge a notification that you will be claiming a tax deduction for the superannuation product from which you are transferring, you may need to do so before you transfer to OneCare Super.

3 Choosing to pay premiums by Rollover may also have implications for tax payable on benefits at time of claim. Please contact your financial adviser or taxation adviser for additional guidance prior to rolling over. 1. Applicant details Title Mr Mrs Ms Miss Dr Other Surname Given name(s) Date of birth (dd/mm/yyyy) DD / MM / YYYY. Residential address (this cannot be a PO Box) . Suburb/Town State Postcode Country Contact phone Tax file number . Please refer to the section titled Providing your Tax File Number' in the OneCare Product Disclosure Statement (PDS). 2. Proof of identity I have attached a certified copy of my current driver's licence or passport or I have attached certified copies of both: Birth/Citizenship Certificate or Centrelink Pension Card and Centrelink payment letter or Government notice (less than one year old) with name/address.

4 Notice issued by Commonwealth, State or Territory within the past 12 months that contains your name and residential address. For example: Tax office Notice of Assessment Rates notice from local council. 1 of 2. 3. Request for partial Rollover of funds A Rollover must fully comprise a Tax Free Component and/or a Taxed Element of a Taxable Component. The Rollover will be rejected if it contains, in whole or in part, an Untaxed Element of a Taxable Component. If issuing a cheque please make payable to OnePath Life Limited' and send to OneCare, OnePath Life Limited, GPO Box 4148, Sydney NSW 2001.

5 I hereby instruct you to transfer to the Retirement Portfolio Service the exact partial Rollover amount of my super/ Rollover fund which is detailed below, Partial Rollover $ (This amount is net of any fees or charges.). From Fund details paying institution Institution Fund name Unique Superannuation Identifier (USI). Member/Policy number Address of paying institution Suburb/Town State Postcode To Fund details receiving institution O N E PAT H L I F E L I M I T E D. Institution RETIREMENT PORTFOLIO SERVICE. Fund name Member number Unique Superannuation 53789980697001.

6 Identifier (USI). Address of receiving G P O B OX 4148. institution SYDNEY NSW 2001. Suburb/Town State Postcode Country AU S T R A L I A. Phone number of 133667. receiving institution 4. Approval to transfer I declare I have read this form and the information completed is true and correct. I Request and consent to the transfer of superannuation as described above and authorise the superannuation provider of each fund to give effect to this transfer. I understand that the trustee of the fund nominated in (3) Fund paying institution is discharged from any liability in respect of any amount transferred.

7 I approve the deduction of any applicable transfer fees, exit fees and taxes from the benefit being transferred (subject to legislative restrictions). I am aware I may ask my superannuation provider for information about any fees or charges that may apply, or any other information about the effect this transfer may have on my benefits, and do not require any further information. To the best of my knowledge, my other superannuation fund(s) is a complying superannuation fund under the Superannuation Industry (Supervision) Act 7 1993. Retirement Portfolio Service is a regulated and complying superannuation fund under the Superannuation Industry (Supervision) Act 1993.

8 I consent to the collection, use, storage and disclosure of my personal information (including health and other sensitive information). as described in the Privacy Policies. OnePath Life's privacy policy is available at and OnePath Custodians' Privacy Policy is available at If I have provided information (including health and other sensitive information) about another person in this application (for example a beneficiary or life insured), I declare that I have the consent of that person to do so. I understand that OnePath Life and OnePath Custodians requires me to inform the person concerned that I have done so and direct them to the Privacy Policies.

9 L7787/0419. I acknowledge that from 31 May 2019, OnePath Life will no longer be a related body corporate of OnePath Custodians.. Signature of applicant Date (dd/mm/yyyy) / / 2 of 2.


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