The information provided in this document is general advice only and has been prepared without taking account of your personal objectives, financial situation or needs. Before acting on any such general advice, you should consider the appropriateness of the advice, having regard to your own objectives, financial situation and needs. You may wish to consult a licensed financial advisor. You should obtain a copy of the CSS Product Disclosure Statement (PDS) or the PSS Product Disclosure Statement (PDS) and consider their content before making any decision regarding your super.Commonwealth Superannuation Corporation (CSC) ABN: 48 882 817 243 AFSL: 238069 RSEL: L0001397 Trustee of the Commonwealth Superannuation Scheme (CSS) ABN: 19 415 776 361 RSE: R1004649 and Public Sector Superannuation Scheme (PSS) ABN: 74 172 177 893 RSE: R1004595

Important information about this form

What this form is forYour accurate completion of the benefit application form allows us to process the application as soon as possible after it is received. Take care when completing this form. If you do not complete the benefit application form correctly, the processing of your benefit will be delayed, or may be paid incorrectly.If you haven’t been provided with an estimate, please contact CSS on 1300 000 277 orPSS on 1300 000 377.Please complete this acknowledgment that you have received and understood sufficient informationto be able to make an informed choice of how you would like your benefit paid.You are making a formal election under the provisions of the Superannuation Act 1990. This election is binding and cannot normally be changed, although Commonwealth Superannuation Corporation (CSC) may, at its absolute discretion, agree to cancel an election in certain circumstances.

How to use this formPlease use a black or blue pen.Mark boxes like this with a or then fill out the next question or section.

Submitting your formPlease send your completed, signed application form and attached documents via:Post:CSS/PSSGPO Box 2252 Canberra ACT 2601AUSTRALIAor email to: formsandapplications@csc.gov.au

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Spouse of a deceased member(contributing or preserved) •1. Explanatory notes •2. Form •3. CSS only form •4. PSS only form

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1. Explanatory notes startThese Explanatory notes are intended to assist you to complete the attached benefit application form. Before completing this benefit application form, you are advised to read the Product Disclosure Statement (PDS) at csc.gov.au.

It is suggested that you separate the notes from the form so that you can refer to them as you complete the application form. We can provide details of your benefit entitlement and explain benefit options.

For more information: CSS Phone: 1300 000 277 Fax: (02) 6275 7010 Email: members@css.gov.au PSS Phone: 1300 000 377 Fax: (02) 6275 7010 Email: members@pss.gov.au

Section A – About the deceased Please complete all the boxes in this section. Please also attach a copy of the full death certificate.

Section B – Your details Please complete all the boxes in this section. It allows us to identify you, and tells us how we can contact you.

Contact details The postal address you provide is where all correspondence will be sent. Contact phone numbers are also required, in case we need to contact you regarding the payment of your benefit. If you have email access, inclusion of your current email address will be helpful.

Section C – Information acknowledgement You must sign this section to acknowledge you have received and understood sufficient information to be able to make an informed choice of how you would like your benefit processed. Information sources are shown at the start of these Explanatory notes and it is strongly recommended that you make use of them before completing this benefit application form. If you do not sign this acknowledgement, processing of your benefit cannot proceed.

Section D – Benefit options You can only select one benefit option otherwise your benefit application will be invalid and processing will be delayed.This section shows all benefit options available to PSS and CSS dependants under this division of the scheme rules. However, depending on your situation, you may not be eligible for some of these options.You can only select one option that has been reflected in your benefit estimate. If you have not obtained a benefit estimate, or your situation has changed since you obtained a benefit estimate, please contact us.You are making a formal election under the provisions of either the Superannuation Act 1990 or the Superannuation Act 1976. This election is binding and cannot be cancelled or withdrawn, although CSC may, at its absolute discretion, agree to change an election in certain exceptional circumstances.

Notes continued on next page

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Section E – Benefit payment detailsPlease complete this section if you are claiming a pension and/or lump sum entitlement. If you want to specify what components should be applied to your benefit, subject to proportioning rules, please attach separate instructions to this benefit application form. You may wish to nominate a different bank account for your pension payments. If this is the case please complete both bank account details sections in Section E.

Section F – Superannuation contributions surcharge If the deceased member had an outstanding superannuation contributions surcharge debt (‘surcharge debt’), you must complete this section. If you elect to have the debt deducted from your lump sum benefit, it will be deducted from any untaxed components in the first instance, unless you instruct otherwise.If you elect to have the debt deducted from your pension entitlement, this will be applied for the lifetime of the pension.This election is binding and cannot be revoked if your circumstances change. You can only make one election for the repayment of your surcharge debt. If you do not provide an election, the processing of your benefit may be delayed.

Section G – Taxation matters Tax File Number (TFN) In accordance with the Taxation Laws Amendment (Tax File Numbers) Act 1988, we are required to deduct PAYG tax at the top marginal rate, plus the Medicare levy, from benefits if a person does not provide a TFN. We are required to validate your TFN with the Australian Taxation Office’s (ATO) records to confirm the TFN provided is yours and is correct. Your TFN will be validated using the SuperTICK validation service. If you do not provide your TFN, the processing of your benefit payment may be delayed. You must also advise of your approval to disclose your TFN to rollover funds.We will provide your TFN to the receiving fund unless you instruct us not to. Please note that there are consequences for not supplying your TFN to the receiving fund.

TFN Declaration form If you have chosen to receive all or part of your benefit as a pension and you wish to claim the tax-free threshold, you should complete a TFN Declaration form and attach it with your benefit application form. These forms are available from your personnel section, the ATO and some newsagencies. If you do not provide us with this form, the tax-free threshold will not be applied to your pension.

Section H – Member checklistWhile it is not compulsory to complete this section, it is recommended that you complete the member checklist to be sure you have completed each section of the benefit application form.

End of explanatory

notes

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The information provided in this document is general advice only and has been prepared without taking account of your personal objectives, financial situation or needs. Before acting on any such general advice, you should consider the appropriateness of the advice, having regard to your own objectives, financial situation and needs. You may wish to consult a licensed financial advisor. You should obtain a copy of the CSS Product Disclosure Statement (PDS) or the PSS Product Disclosure Statement (PDS) and consider their content before making any decision regarding your super.Commonwealth Superannuation Corporation (CSC) ABN: 48 882 817 243 AFSL: 238069 RSEL: L0001397 Trustee of the Commonwealth Superannuation Scheme (CSS) ABN: 19 415 776 361 RSE: R1004649 and Public Sector Superannuation Scheme (PSS) ABN: 74 172 177 893 RSE: R1004595

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Spouse of a deceased member(contributing or preserved)

Read the Explanatory notes and each section of the form carefully before filling it in.

A About the deceased member1. Member detailsReference number (AGS)

Title Mr Mrs Ms Miss Other

Surname

Given name(s)

Date of birthD D M M Y Y Y Y

/ /

Date of deathD D M M Y Y Y Y

/ /

2. Scheme details

Some members have more than one scheme or several memberships. Please provide AGS numbers for each membership:

Reference number (AGS) Scheme

Reference number (AGS) Scheme

Reference number (AGS) Scheme

B About you3. Your detailsTitle Mr Mrs Ms Miss Other

Surname

Given name(s)

2. Form start

Section B continued on next page

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Date of birthD D M M Y Y Y Y

/ /

AddressRESIDENTIAL ADDRESS

SUBURB STATE POSTCODE

POSTAL ADDRESS

SUBURB STATE POSTCODE

Phone numberBUSINESS HOURS

AFTER HOURS

MOBILE NUMBER

Would you like to receive an SMS to confirm we have received your application?

No Yes

Email address

@

If you provide your email address, we will provide your pension advice letter and Payment Summary electronically via Pensioner Services Online and notify you by email of when they are available. Please tick this box if you want paper copies of those documents to be sent to the postal address above instead. You can change your communication preference at any time via Pensioner Services Online.

C Information acknowledgement4. Please sign and date the following acknowledgement before returning your

application to us(Benefit processing may be delayed if this acknowledgment is NOT completed)I declare that:• I have been given enough information to make an informed decision about how I would like my

benefit to be paid • I also understand that, by choosing a benefit option in Section D, I am making a formal election

under the provisions of the CSS or PSS legislation and this benefit election cannot be changed except in certain circumstances approved by us

• the information I have provided is true and correct to the best of my knowledge• I acknowledge that it may be a criminal offence to knowingly provide false or misleading

information or documents.

SIGNATURE Date signedD D M M Y Y Y Y

/ /

If you need more information, or would just like to talk about the options you have, please contact CSS on 1300 000 277 or PSS on 1300 000 377.

End Form

Sign

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3. CSS only to complete Form startFor PSS go to page 10.

D Benefit options5. Please ensure that only one benefit option is completed.OPTION 1. Maximum pension and lump sum of productivity component and any supplementary contributions

I, GIVEN NAME(S)

SURNAME

elect to take my benefit as a maximum pension plus a refund of my productivity component and any supplementary contributions.

SIGNATURE Date signedD D M M Y Y Y Y

/ /

You have now completed this section. Go to Section E to tell us how you would like your pension and lump sum paid.

OPTION 2. Standard CPI indexed pension and lump sum of member and productivity components

I, GIVEN NAME(S)

SURNAME

elect to take my benefit as a standard CPI-indexed pension plus a lump sum of my member and productivity components.

SIGNATURE Date signedD D M M Y Y Y Y

/ /

You have now completed this section. Go to Section E to tell us how you would like your pension and lump sum paid.

Sign

Sign

Section D continued on next page

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OPTION 3. Lump sum, no pension (Only available if your spouse was a former Provident Account member. Please check your benefit estimate to see if this option is available to you in your circumstance.)

I, GIVEN NAME(S)

SURNAME

elect for a Provident Account lump sum.

SIGNATURE Date signedD D M M Y Y Y Y

/ /

If there is an outstanding superannuation contributions surcharge debt it will be deducted from your lump sum. You have now completed this section. Go to Section E to tell us how you would like your pension and lump sum paid.

OPTION 4. Lump sum only, less than 15 years’ contributory service and benefit reduced on medical grounds

I, GIVEN NAME(S)

SURNAME

elect to take my benefit as a lump sum.SIGNATURE Date signed

D D M M Y Y Y Y

/ /

If there is an outstanding superannuation contributions surcharge debt it will be deducted from your lump sum. You have now completed this section. Go to Section E to tell us how you would like your pension and lump sum paid.

E Benefit payment details6. Bank account details for pension paymentsPlease note that pensions can only be paid to an account in your name and must be in Australia. This can be a joint account.Type of financial institution Savings bank Building society Credit union

Account held in the name of

Name of account holder

Branch location

BSB number --Note: If the BSB or account number you provide is incorrect the payment will not be accepted by your financial institution. If you have any doubts what your correct BSB or account number is, you should confirm these details with your financial institution before including them in this form.

Account number

Sign

Section E continued on next page

Sign

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Bank account details for pension lump sum paymentsPlease note that pensions can only be paid to an account in your name and must be in Australia. This can be a joint account.

Type of financial institution Savings bank Building society Credit union

Account held in the name of

Name of account holder

Branch location

BSB number --Note: If the BSB or account number you provide is incorrect the payment will not be accepted by your financial institution. If you have any doubts what your correct BSB or account number is, you should confirm these details with your financial institution before including them in this form.

Account number

The information I have supplied is true and correct.

SIGNATUREDate signed

D D M M Y Y Y Y

/ /

You have now completed this section. Go to Section F to tell us how you would like your outstanding superannuation contributions surcharge debt deducted.

F Superannuation contributions surchargeI would like my outstanding superannuation contributions surcharge debt to be deducted from either:

my standard CPI-indexed pension

OR my additional non-indexed pension (if applicable)

OR my lump sum (if applicable).

G Taxation mattersUnder the Superannuation Industry (Supervision) Act 1993, your superannuation fund is authorised to collect your Tax File Number (TFN), which will only be used for lawful purposes.These purposes may change in the future as a result of legislative change. We may disclose your TFN to another superannuation provider, when your benefits are being transferred, unless you request in writing that your TFN not be disclosed to any other superannuation provider.It is not an offence not to quote your TFN. However giving us your TFN will have the following advantages (which may not otherwise apply):• we will be able to accept all types of contributions (subject to scheme rules)• the tax on contributions to your superannuation account/s will not increase• other than the tax that may ordinarily apply, no additional tax will be deducted when you start

drawing down your superannuation benefits and

• it will make it much easier to trace different superannuation accounts in your name so that you receive all your superannuation benefits when you retire.

If you have already provided your TFN to us, you are under no obligation to provide it again.

What is your TFN?

Sign

Section G continued on next page

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Emailmembers@css.gov.aumembers@pss.gov.au

PhoneCSS: 1300 000 277PSS: 1300 000 377

Fax(02) 6275 7010

PostCSS/PSSGPO Box 2252Canberra ACT 2601

Web csc.gov.au

Overseas Callers+61 2 6275 7000

7. Tax File Number (TFN) declarationPlease provide us with a completed TFN declaration form. It is not an offence to not quote your TFN. However, if you do not provide your TFN, we are required to withhold tax on any benefit paid to you at the highest marginal tax rate.TFN declaration forms (form number: NAT 3092) are available from either:

• an Australian Post Office or

• the Australian Taxation Office or

• you may request that we send a TFN declaration form to you.Under the Superannuation Industry (Supervision) Act 1993, a super Fund is authorised to collect your TFN, which will only be used for lawful purposes. These purposes may change in the future as a result of legislative change.

H Member checklistI have: read all the Important information about this form,

received a benefit estimate, and any other information I require to make an informed decision

filled in all the sections applicable to me signed the Information acknowledgement at Section C signed an election option in Section D completed the bank account details in Section E provided my TFN in Section G (for pension recipient only)

attached my completed Tax File Number declaration form (for pension recipients only).

You have now completed this form. Please return this form direct to us via:Post:CSS/PSS GPO Box 2252 Canberra ACT 2601 AUSTRALIAor email: formsandapplications@csc.gov.au

Need assistance? Call us on the phone numbers below

End CSS only form

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4. PSS only to complete Form startFor CSS go to page 6.

D Benefit options4. Please ensure that only one benefit option is completed.OPTION 1. Pension only, no lump sum

I, GIVEN NAME(S)

SURNAME

elect to take my entire benefit as a full CPI-indexed pension.SIGNATURE Date signed

D D M M Y Y Y Y

/ /

You have now completed this section. Go to Section E to tell us how you would like your pension and lump sum paid.

OPTION 2. Part pension and part lump sum

I, GIVEN NAME(S)

SURNAME

elect to take my benefit as a pension and part as a lump sum.

I wish to convert

%

of my benefit (your estimate specifies minimum amounts) to a pension, with the balance to be paid as a lump sum.

OR

I wish to be paid a lump sum benefit of

$ (gross) (your estimate specifies maximum amounts), with the balance to be converted to a pension.

SIGNATURE Date signedD D M M Y Y Y Y

/ /

You have now completed this section. Go to Section E to tell us how you would like your pension and lump sum paid.

Sign

Sign

Section D continued on next page

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OPTION 3. Lump sum, no pension

I, GIVEN NAME(S)

SURNAME

elect to take my benefit as a lump sum.SIGNATURE Date signed

D D M M Y Y Y Y

/ /

You have now completed this section. Go to Section E to tell us how you would like your pension and lump sum paid.

OPTION 4. Limited benefits lump sum only, no pension

Only applicable if the deceased member was a limited benefits member.

I, GIVEN NAME(S)

SURNAME

apply to take my benefit as a lump sum.SIGNATURE Date signed

D D M M Y Y Y Y

/ /

E Benefit payment details5. Bank account details for pension paymentsPlease note that pensions can only be paid to an account in your name and must be in Australia. This can be a joint account.Type of financial institution Savings bank Building society Credit union

Account held in the name of

Name of account holder

Branch location

BSB number --Note: If the BSB or account number you provide is incorrect the payment will not be accepted by your financial institution. If you have any doubts what your correct BSB or account number is, you should confirm these details with your financial institution before including them in this form.

Account number

Sign

Sign

Section E continued on next page

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Bank account details for pension lump sum paymentsPlease note that pensions can only be paid to an account in your name and must be in Australia. This can be a joint account.

Type of financial institution Savings bank Building society Credit union

Account held in the name of

Name of account holder

Branch location

BSB number --Note: If the BSB or account number you provide is incorrect the payment will not be accepted by your financial institution. If you have any doubts what your correct BSB or account number is, you should confirm these details with your financial institution before including them in this form.

Account number

The information I have supplied is true and correct.

SIGNATUREDate signed

D D M M Y Y Y Y

/ /

You have now completed this section. Go to Section F to tell us how you would like your outstanding superannuation contributions surcharge debt deducted.

F Superannuation contributions surchargeI would like my outstanding superannuation contributions surcharge debt to be deducted from either:

my standard CPI-indexed pension

OR my additional non-indexed pension (if applicable)

OR my lump sum (if applicable).

G Taxation mattersUnder the Superannuation Industry (Supervision) Act 1993, your superannuation Fund is authorised to collect your TFN, which will only be used for lawful purposes.These purposes may change in the future as a result of legislative change. We may disclose your TFN to another superannuation provider, when your benefits are being transferred, unless you request in writing that your TFN not be disclosed to any other superannuation provider.It is not an offence not to quote your TFN. However giving us your TFN will have the following advantages (which may not otherwise apply):• we will be able to accept all types of contributions (subject to scheme rules)• the tax on contributions to your superannuation account/s will not increase• other than the tax that may ordinarily apply, no additional tax will be deducted when you start

drawing down your superannuation benefits and

• it will make it much easier to trace different superannuation accounts in your name so that you receive all your superannuation benefits when you retire.

If you have already provided your TFN to us, you are under no obligation to provide it again.

What is your TFN?

Section G continued on next page

Sign

ASDM 12 of 13

Emailmembers@css.gov.aumembers@pss.gov.au

PhoneCSS: 1300 000 277PSS: 1300 000 377

Fax(02) 6275 7010

PostCSS/PSSGPO Box 2252Canberra ACT 2601

Web csc.gov.au

Overseas Callers+61 2 6275 7000

6. Tax File Number (TFN) declarationPlease provide us with a completed TFN declaration form. It is not an offence to not quote your TFN. However, if you do not provide your TFN, we are required to withhold tax on any benefit paid to you at the highest marginal tax rate.TFN declaration forms (form number: NAT 3092) are available from either:• an Australian Post Office

or• the Australian Taxation Office

or• you may request that we send a TFN declaration form to you.Under the Superannuation Industry (Supervision) Act 1993, a super Fund is authorised to collect your TFN, which will only be used for lawful purposes. These purposes may change in the future as a result of legislative change.

H Member checklistI have: read all the Important information about this form, received a benefit estimate,

and any other information I require to make an informed decision filled in all the sections applicable to me signed the Information acknowledgement at Section C signed an election option in Section D completed the bank account details in Section E provided my TFN in Section G (for pension recipient only) attached my completed Tax File Number declaration form (for pension recipients only).

You have now completed this form. Please return this form direct to us:Post:CSS/PSS GPO Box 2252 Canberra ACT 2601 AUSTRALIAor email: formsandapplications@csc.gov.au

Need assistance? Call us on the phone numbers below

End Attachment

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