DASP - Departing Australia Superannuation Payment Acknowledgement Form

Title *

Mr

Mrs

Miss

Ms

Full Name (as shown on passport) *

Have you ever had a name change? *

Yes - provide details on next question

No - jump to the question 6

If your Name has changed, what was your Previous Name?

If your Name has changed, what was the reason? (please note you will need to provide proof of change of name during the Super process)

Deed

Marriage

Divorce

Other

Date of Birth (DD/MM/YYYY) *

Mobile Number *

Email address *

Last Residential Address in Australia (Street, Number, City, State, and Post Code) *

Street Address *

City *

State *

Country *

Postal code *

Name of Superannuation Fund *

How many Superannuation accounts do you hold? *

1 Account

2 Accounts

3 Accounts

Name of Superannuation Fund 2

Name of Superannuation Fund 3

Passport Country (Please note that we will need an Authenticated Copy of your Passport for the application) *

Passport Number *

Tax File Number *

What types of Visa(s) did you hold during your stay in Australia? *

Did you hold any other types of Visa(s) during your stay in Australia?

Yes

No

What types of Visa(s)

What was your last VISA number?

Which Date you have arrived in Australia? *

Which Date you have Departed from Australia? *

What was the Date of your last Employment in Australia? *

When does your Visa Expires/Expired? *

Do you still hold an Australian Bank account?

Yes

No

Bank Name

BSB (agency number)

Account Number

International Bank Name

International Bank Account Name

Switch Code

IBAN Number (ask your bank, or get from your bank statement)

International Bank Address (Street, Street Number, City, State, Country and Post Code)

By Signing this form, you declare that all information given is TRUE; you agree for us to collect your personal details, including your TFN to collect your Super data on the ATO's portal; and to act on your behalf to apply for the Departing Australia Superannuation Payment through the DASP ATO Agent's Portal, providing your TFN on the application process.

You also agree to pay BAS & Books for You the DASP Online Application fees as described on your booking details.

We won't proceed with your Super Payment Process without your consent.

If you do not agree with these conditions, then do not submit this form.

Electronic signatures count as original for all purposes.

Signature *

Clear