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Financial Hardship Guide

Rules for early access to your super

Issued: July 2012

Contents

Rules at a glance .................................................................................. 3 What proof do I need?...................................................................... 4 How much can I claim? ................................................................... 6 Frequently asked questions .......................................................... 7 Completing the form ........................................................................ 8

Contact Centres 70 Eagle Street Brisbane 63 George Street Brisbane Ph 1300 360 750 (+617 3239 1004 if overseas) Fax 1300 241 602 (+617 3239 1111 if overseas) Monday to Friday 8.30am to 5.00pm AEST GPO Box 200 Brisbane Qld 4001

Australian business number (ABN): 60 905 115 063, Superannuation fund number (SFN): 2610 419 41, Superannuation product identification number (SPIN), Accumulation account: QSU0101AU, Defined Benefit account: QSU0102AU. This information is provided by the fund administrator, QSuper Limited (ABN 50 125 248 286, AFSL 334546), which is wholly owned by the Board of Trustees of the State Public Sector Superannuation Scheme (ABN 32 125 059 006) (QSuper Board). This information has been prepared for general purposes only without taking into account your objectives, financial situation, or needs. As a result, you should consider the appropriateness of the information for your circumstances and read the product disclosure statement (PDS) before deciding whether to acquire, or continue to hold, a product. You can obtain a PDS at qsuper.qld.gov. au or by calling us on 1300 360 750. All products are issued by the QSuper Board as trustee for the QSuper Fund (ABN 60 905 115 063). Where the term `QSuper' is used in this document, it represents the QSuper Board, the QSuper Fund and QSuper Limited, unless expressly indicated otherwise. © QSuper Board of Trustees 2012

qsuper.qld.gov.au

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Financial Hardship Guide July 2012

Rules at a glance

Please read all the information before completing the application form in this guide. On completion, the application form needs to be posted or delivered to QSuper. A faxed application cannot be accepted. Generally, superannuation can only be claimed when you permanently retire from the workforce after reaching your preservation age (55 to 60, depending on your date of birth), or on earlier death or total and permanent disability. However, Commonwealth Government legislation permits earlier access to your benefits in other very limited circumstances. These circumstances include severe financial hardship or certain compassionate grounds. This guide is about accessing your superannuation due to severe financial hardship. A separate guide is available from QSuper for claims on compassionate grounds.

Commonwealth legislation allows the release of superannuation in proven cases of severe financial hardship.

Rules at a glance

Generally, superannuation can only be claimed on retirement, death, or total and permanent disability. Commonwealth legislation allows the release of superannuation in proven cases of severe financial hardship, which this guide is about. prove severe financial hardship, you need to To show both of the following: ­ you have been (and still are) receiving eligible Commonwealth Government income support payments (like Newstart) for a continuous period of at least 26 weeks, and ­ you're unable to meet reasonable and immediate family living expenses from your current income and assets. This guide shows you how to demonstrate you meet these requirements. you are unable to demonstrate you meet the If requirements, as shown in this guide, your claim cannot be approved. you are over 55 and 39 weeks, there is an If alternative set of rules you can apply under. These are described on page 5. you are unable to prove financial hardship, If you may want to consider making a claim on compassionate grounds instead. For detailed information, you can download a copy of the QSuper Compassionate Grounds Guide from our website, or call us and we'll send you a copy.

Financial Hardship Guide July 2012

3

What proof do I need?

Who decides what is severe financial hardship?

Commonwealth Government rules provide guidelines for determining whether severe financial hardship exists. QSuper is required to follow these guidelines when considering whether your superannuation can be released, so you'll need to be able to prove financial hardship, as shown in this guide, for QSuper to be allowed to release your money.

How do I prove I'm getting income support benefits?

To prove you are currently receiving Commonwealth Government income support payments, and have been for the past 26 weeks, you need a letter from the agency making your payments (normally Centrelink), showing the payments you're receiving and the period you have been receiving them for. Centrelink will generally provide you with a Q230 form to forward to QSuper. This form must be current at the time of your application and is only valid for 21 days.

What proof do I need to supply to QSuper?

You need to prove you are both: currently receiving Commonwealth Government income support payments (such as Newstart), and have been doing so for a continuous period of at least 26 weeks. You must provide a Q230 form from Centrelink. Being in receipt of Austudy or youth allowance (if you are studying full-time) will not enable you to meet this requirement, and unable to meet your reasonable and immediate family living expenses from your income. Alternatively, if you are over age 55, you could prove you have received payments for a cumulative 39-week period (Q251 form from Centrelink) at some point since turning 55, and are currently not employed for more than ten hours per week. This is described in more detail on page 5.

How do I prove I can't pay my current bills and expenses?

To prove you are unable to meet your reasonable and immediate family living expenses from your current income, you need to complete the claim form and statutory declaration in this guide. This guide is designed to explain and help you through this process.

Do I need to prove both these conditions for my claim to be paid?

Yes. The Commonwealth Government guidelines state the trustees of any super fund, such as QSuper, must be satisfied these conditions are met for them to be able to release your money. If you cannot show you meet these conditions, QSuper will be unable to release your superannuation on financial hardship grounds.

Commonwealth Government rule s provide guideline s for determining whether severe financial hardsh ip exists.

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Financial Hardship Guide July 2012

What proof do I need?

Why does QSuper ask me about assets and liabilities?

Part C of the attached form asks you to provide information about your assets and liabilities so we can determine if you have assets that can be used to meet your reasonable and immediate family living expenses. Your family home does not need to be listed. However, we do need to know about any liquid assets you may have, such as cash, shares, or other things that could realistically be sold to cover your expenses. If their net value exceeds $50,000, these liquid assets must be used to meet your expenses before consideration can be given to releasing your superannuation. The information about your assets and liabilities is used to ensure your net liquid assets are under $50,000. For QSuper to pay your claim, you need to be able to answer `yes' to the question regarding assets in part C of the form.

Options for members over 55

If you are over 55, you can apply for early access under the rules contained in this guide. These rules require you to show you have been receiving Commonwealth Government income support for at least 26 weeks, and are unable to meet reasonable and immediate family living expenses from your current income and assets. Under these rules you can apply for an amount up to $10,000. Alternatively, if you're over 55 and 39 weeks, you can claim up to your full account balance if you: have been receiving Commonwealth Government income support payments for a cumulative period of 39 weeks after having reached 55, and not gainfully employed on a full-time or are part-time (more than ten hours per week) basis when you apply. To apply using this alternative method, you need proof of income support payments (form Q251 from Centrelink). If you're over 55 and 39 weeks and can provide this proof, you don't need to provide any other information about your financial circumstances in order to claim. You can disregard the parts of this guide and application form that describe how you tell QSuper about your income, expenses, assets, and liabilities. So, members using this alternative method: don't need to complete part C of the form ­ no proof of expenses is required not subject to the $10,000 limit on claims ­ you are can claim up to your full account balance, and

We do need to know about any liquid assets you may have.

not restricted to making a claim only once in a are twelve-month period.

Financial Hardship Guide July 2012

5

How much can I claim?

The amount you can claim depends on the extent to which you are unable to meet your expenses on your current income. You should only apply for the amount needed to meet twelve months of your net expenses, and to prevent you suffering more debt from these expenses. The maximum amount that can be released is $10,000 gross. QSuper may be required to deduct tax from the amount released. You should read the remainder of this guide and then use the worksheet below to estimate how much you can claim. QSuper will hold a minimum amount of $100 of the account balance if an employer is still contributing to QSuper on the member's behalf. This is in order to maintain a current account for the receipt of future contributions and to ensure that premiums for insurance can be paid.

You should only apply for the amount needed to meet twelve months of your net expenses.

Claim worksheet

When you get to part C of the claim form, take the figure that shows the amount by which you are unable to meet your fortnightly expenses with your current income and enter it in the box below. 1. $ Multiply this figure by 26 to get an annual amount and enter it in the box below. 2. $ Total any one-off immediate expenses (e.g. repair to fridge, car or overdue amounts on your bills) and enter it in the box below. HECS debts don't count as part of this category. 3. $ Total amount you can claim (add 2 and 3 above) 4. $ You need to enter the total amount you can claim (above) in the box in part B on page 1 of the form where it asks how much you are claiming. You also need to keep this calculation, as QSuper may request further information regarding your claim.

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Financial Hardship Guide July 2012

Frequently asked questions

How often can I claim?

Only one claim for financial hardship can be approved in any twelve-month period. This is why it's important to carefully calculate the amount you are claiming. If your claim is not approved, you can apply again as soon as you believe your circumstances would allow a claim to be paid. It may be necessary for QSuper to deduct tax from the payment. For more information, read our Tax Explanation factsheet. You can download a copy from our website, or call us and we'll send you one. The amount payable before any tax is deducted is referred to as the gross amount. The amount payable after any required tax is deducted is referred to as the net amount.

How long will it take for my claim to be assessed?

If your claim is successful you'll normally receive funds within two weeks. However, applications submitted without all requested information might take longer to assess, as we'll need to obtain that information from you. Your claim may also take longer to process if we need to check details of your claim with you, or if you need to transfer between accounts (see below). Reading this guide carefully, answering honestly, and including all requested information will help ensure your claim is assessed as quickly as possible. If a claim is approved, only monies held in a QSuper Accumulation account can be released. Members with a Defined Benefit account or a deferred retirement benefit will need to transfer their benefit to an Accumulation account if their claim is approved. The process of transferring the benefit to an Accumulation account will delay the processing time for payment and can take up to four weeks. It's important you don't transfer your funds into an Accumulation account before you have approval for your funds to be released, as once you have left a Defined Benefit account or deferred retirement benefit you cannot transfer back.

Need more information?

We're committed to making it easier for you to understand your options, so you can feel confident that you are making the right choices for your super. If you have any questions about this guide, or your super in general, call us or visit our website for useful information, tools, and calculators. Written enquiries can be addressed to: QSuper GPO Box 200 BRISBANE QLD 4001

qsuper.qld.gov.au 1300 360 750

To I have the Accumulation account, Dotransfer toto pay tax on the amount paid? you must do one of the following:

Members with a Defined Benefit account need to consider the information contained in the Defined Benefit Account Guide and then complete the Defined Benefit to Accumulation Account Transfer form should they want to proceed.

Members with a deferred retirement benefit need to consider the information contained in the Deferred Retirement Benefit Guide and complete the Investment Linked Option Application form should they want to proceed.

Members with a State or Police account, need to contact QSuper.

If your claim is successful you'l l normally receive funds within two weeks.

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7

Completing the form

Do I have to show my income and expenses?

Yes. The part of the application form about income and expenses helps you and QSuper determine the extent to which you are unable to meet your reasonable and immediate family living expenses. It will also help determine the amount that can be released. If you're single, your own details will be assessed. If you're applying as a family, the combined assets, liabilities, income, and expenses of you and your family will be assessed. As mentioned earlier, your expenses must be reasonable in view of your own personal circumstances, and they must be due for payment at the time of your application. Reasonable living expenses would include: normal living expenses, such as groceries, electricity and phone expenses for medical supplies for a condition you or a dependent family member may be suffering school fees, books or other costs related to education of school-aged children. Business expenses will not be considered unless they are expenses you're personally liable for, e.g. car repayments where the car is used personally by you as well as your business, or if your business has failed and you are personally liable for the business debts. In such circumstances the expenses may be relevant to being unable to meet your reasonable and immediate family living expenses. You need to show all forms of income, including income support payments, maintenance payments, interest on bank accounts, and income from any part-time or full-time work. Where your reasonable and immediate family living expenses can be met from your income, QSuper is unable to release your superannuation. You need to be able to answer `yes' to the question regarding income and expenses in part C of the form. As noted on page 5 of this guide, this proof is not required if you are over 55 years and 39 weeks and using the alternative method.

Do I need to send receipts and documents to prove my expenses?

You don't need to send this information but you do need to keep it, as we may ask you to provide it as further information relating to your claim. As part of the claim process, you are signing a declaration stating you have kept this information and agree to supply it should QSuper need it. You are also signing a statutory declaration stating all information you have supplied is true and correct. Penalties exist for false declarations. A registered justice of the peace (JP), commissioner for declarations (CD), lawyer, or notary public must witness your statutory declaration, which is a legal document. If your declaration is witnessed by a JP or CD, they must also provide their registration number and stamp. A QSuper officer who is not qualified as one of the above is not able to witness your statutory declaration. The Department of Justice and Attorney-General's website, www.justice.qld.gov.au, has the details of JPs who are willing to be contacted to provide a signature.

Your expenses m ust be reasonable in view of your own pers onal circumstances, and they must be du e for payment at the t ime of your application.

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Financial Hardship Guide July 2012

Application For Early Access To Eligible Benefits For Severe Financial Hardship (Part 1)

Please refer to the important notes on page 5 where you see this symbol. Also see the additional information about the form on page 5. Please complete in dark blue or black ink.

What do I use this form for?

You should use this form if you want to apply for early access to your preserved benefits on severe financial hardship.

Part A Personal details

Mr/Mrs/Ms/Miss/Dr/other (please specify) Given names Postal address State Residential address State Date of birth (dd/mm/yyyy) Phone number (home) Email address

1 If your name has changed since you last had contact with QSuper, please contact us for information on the additional documents you will need to provide.

Surname

Postcode

Postcode

Previous name1 Phone number (work) Phone number (mobile)

Part B Application details

I want to apply for the early release of funds on the grounds of severe financial hardship. To support my claim, I have: attached the original statement of income support payments (Centrelink form Q230 or Q251). completed and attached the statutory declaration. completed part C of the form confirming my net liquid assets are under $50,000, and my reasonable and immediate living expenses are unable to be met from current income (not required if over 55 and 39 weeks and using alternative method described on page 5). These requirements must be met for your claim to be processed. Amount you are claiming Unless you are over 55 and 39 weeks and claiming under the alternative method, you can only apply to have monies released once each twelve-month period. You should consider your expenses over this period and only apply for the amount needed to assist with meeting your reasonable and immediate living expenses over that time. The maximum amount you can apply for is your account balance, or $10,000 gross2 (whichever is the lesser). To calculate this amount, you need to note the conditions and use the worksheet on page 6 of the attached guide. I want to apply for a gross amount of

$

2 If payment is approved, tax may be deducted from your benefit.

Please read the notes on page 5 of this form before providing your TFN.

Tax file number (TFN)

If you have previously given your TFN to QSuper, you do not need to supply it again.

Continued over page 1/5

Application For Early Access ­ Severe Financial Hardship (Part 1) continued

Part C Financial details

I am applying as a:

Net assets

single

or

family applicant

Income/expenditure

A. Assets (excluding your home) Savings Vehicle/s Furniture Other items Total (A) B. Liabilities Personal loan Credit cards Other debts Total (B) $ $ $ $ $ $ $ $ $

C. Income (calculate fortnightly) Combined net salary Income support payments Other income Total (C) D. Living expenses (calculate fortnightly) Minimum credit card and loan repayments Rent/board/rates Groceries/petrol Electricity/gas/phone House/car insurance School costs Other Total (D) $ $ $ $ $ $ $ $ $ $ $ $

Net assets A $ less B $ = $

Surplus/deficit C $ less D $ = $ Yes Yes No No

Does the above show your net liquid assets are less than $50,000? Are your reasonable and immediate living expenses more than your income?

If you have answered yes to both these questions, you may be entitled to access your QSuper benefit on severe financial hardship grounds. You should complete the remainder of this form. If you have answered no to either of these questions, your claim cannot be approved. However, you may want to consider a claim for early release on compassionate grounds, which allows access to superannuation to pay for medical assistance or funeral bills, and to provide mortgage assistance. For more information about compassionate grounds, contact QSuper.

Part D Payment method

Pay directly into my bank, credit union, or building society account.

Name of bank, credit union, or building society Account name Branch name Branch address Account number Branch (BSB) number

To ensure the security of your benefits, QSuper requires a copy of the part of bank, credit union, or building society account statement or passbook that contains your full name, address, and financial institution account details. This needs to be received before payment can be made into your account.

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Application For Early Access ­ Severe Financial Hardship (Part 1) continued

Part E

Withdrawal instructions

Amount $ $ $ $ $ $ $ $ $ $ or or or or or or or or or or 100% Percentage % % % % % % % % %

Investment option QSuper Balanced (Default) QSuper Moderate QSuper Socially Responsible QSuper Indexed Mix QSuper Aggressive Cash Diversified Bonds International Shares Australian Shares Total

Part F

Identification requirements

The QSuper Board is committed to complying with the AntiMoney Laundering and CounterTerrorism Financing Act 2006. In line with QSuper's anti-money laundering and counter-terrorism program, we require identification details with any claim you initiate on your QSuper account or as part of a claim as a beneficiary of a QSuper member's account. If you are acting on behalf of a QSuper member (e.g. under a power of attorney), both you and the QSuper member must supply identification as described in this part of the form. A certified copy of the power of attorney is also required. You must provide a certified copy of one of the following current documents, which must contain your name, photograph, and either date of birth or residential address. Please indicate which document you have attached:

a current Australian driver's licence OR I have attached certified copies of both: a birth/citizenship certificate or Department of Human Services pension card and a Department of Human Services payment letter or Government notice e.g. Tax Office notice of assessment (less than 1 year old), or rates/electricity/gas notice (less than 3 months old) a current Australian passport (or one which has expired within the past two years)

If you are unable to provide any of the above documents, please contact the QSuper Contact Centre on 1300 360 750 (+617 3239 1044 if overseas) for information on other documents you may provide to verify your identity. See below for certification procedures and a list of approved certifiers.

Certification procedure

Take the original and a copy of your selected documents to an acceptable certifier (see list below), who will verify that the original documents have been sighted. Ensure that the certifier sights the original and signs the copy, confirming it is a true copy of the original. The certifier must also include their name, the date of certification, and their certifying designation from the list of acceptable certifiers. Post this form and the certified copy of your identification to QSuper. We cannot accept facsimiles or copies of the certified documents. Please do not send us your original documents.

Who to see

Banking and other financial institutions Justice of the peace, commissioner for declarations, or notary public Legal professionals/law enforcement Accountants Consular or Diplomatic Officer

Conditions and definitions

An officer with two or more continuous years of service with one or more financial institutions or a finance company officer with two or more continuous years of service with one or more financial companies. An individual appointed by the courts whose duties include certifying documents. A person who is enrolled on the roll of the Supreme Court of a State or Territory, or High Court of Australia, as a legal practitioner. Other professionals include a judge of a court, a magistrate, a chief executive officer of a Commonwealth court, a registrar or a deputy registrar of a court, or a police officer. A member of the Institute of Chartered Accountants in Australia, CPA Australia, or the National Institute of Accountants, with two or more years of continuous membership. An Australian Consular Officer or an Australian Diplomatic Officer.

Continued over page

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Application For Early Access ­ Severe Financial Hardship (Part 1) continued

Part G Declaration and authorisation

Prior to signing this declaration and authorisation, please ensure that you have completed the checklist below and attached all necessary documentation. have attached a Centrelink statement (Q230 or Q251) to I my application. have completed the statutory declaration (part 2) of this I form and understand there can be penalties for making false declarations (see page 8 of the guide). have completed part C (page 2) of this form and answered I `yes' to both questions (not required if over 55 and 39 weeks and using alternative method described on page 5 of this guide). have read the information about supplying my tax I file number. agree to provide further information to substantiate I my claim should QSuper require it.

Date (dd/mm/yyyy)

declare the information provided in this form is true I and correct. have attached a copy of my banking details, as described I in part D (page 2) of this form. have supplied the necessary documentation to comply I with the AntiMoney Laundering and CounterTerrorism Financing Act 2006, as outlined in part F (page 3) of this form.

Signature

Checklist ­ making sure your claim is paid

QSuper wants to make sure your claim is processed as quickly and easily as possible. To help us do this, please take a few moments to review the following checklist ­ it will help ensure you complete this form correctly, and remind you to attach any necessary documents before sending this form to us.

I have supplied the information requested in part F (page 3) of this form in line with QSuper's anti-money laundering and counter-terrorism financing program. Have you completed and signed the declaration and authorisation in part G above? Have you answered `yes' to the two questions in part C (page 2) of this form about your assets, income and expenses? Have you attached a Q230 or Q251 form from Centrelink (or other appropriate evidence of Commonwealth Government income support)? Have you kept all receipts and calculations, in case QSuper needs to see this information? Have you completed the statutory declaration (part 2) of this form, declaring all information is true and correct? Have you had your statutory declaration witnessed by a registered justice of the peace, commissioner for declarations, lawyer, or notary public? Have you provided your tax file number (if you haven't previously given it to QSuper)? Have you provided a copy of your statement from your bank, credit union or building society, showing the account name, BSB, and account number so we can pay your claim?

Please ensure you complete the Statutory Declaration (part 2) over the page and attach it to this part of the form before sending it to QSuper.

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Application For Early Access ­ Severe Financial Hardship (Part 1) continued

Important notes

Part C This section allows you to show: your net liquid assets are under $50,000, and your reasonable and immediate living expenses are unable to be met from your current income. You must be able to prove both these conditions for your claim to proceed. If you are single, then the items relate only to you. If you have a family, then the items listed relate to combined assets, income, and expenses. QSuper may ask you to provide evidence to substantiate the amounts shown, but we'll contact you if this information is required. Part D Payment must be made to your personal account, not a business or loan account.

Additional information about this form

Providing your tax file number (TFN) Under 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. The trustee of your superannuation fund may disclose your TFN to another superannuation provider when your benefits are being transferred, unless you request the trustee of your superannuation fund 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 your TFN to your superannuation fund will have the following advantages (which may not otherwise apply):

your superannuation fund will be able to accept all types of contributions to your account/s 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

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. Please read the information provided in the attached guide before completing this application. To be eligible to claim your preserved benefits on the grounds of severe financial hardship, you need to prove you cannot meet reasonable and immediate family living expenses. The QSuper Board of Trustees cannot approve your application if your fortnightly income exceeds your fortnightly expenditure. If payment is approved, tax may be deducted from your benefit. Of course, benefits paid to you after age 60 are tax-free. Please refer to the Tax Explanation factsheet for further information. Please ensure you have attached all necessary documentation.

Contact Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Telephone 1300 360 750 (+61 7 3239 1004 if overseas) Monday ­ Friday 8.30am to 5.00pm AEST

Postal address GPO Box 200 Brisbane Qld 4001 Fax 1300 242 070 Website qsuper.qld.gov.au

ABN: 60 905 115 063 SFN: 2610 419 41 5752 07/12 IB06

This document is issued by the Board of Trustees of the State Public Sector Superannuation Scheme (ABN 32 125 059 006) (QSuper Board). All products are issued by the QSuper Board as trustee for the QSuper Fund (ABN 60 905 115 063). The privacy of your personal information is important to us. QSuper Limited (ABN 50 125 248 286, AFSL 334546) is collecting this information on behalf of the QSuper Board to administer your superannuation account. This is authorised under the Superannuation (State Public Sector) Act 1990. This information may be disclosed to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies. QSuper may also disclose this information to third parties if it is necessary in providing our products and services to you, or you have consented to the disclosure, or disclosure is required by law. If you would like further information about our privacy policy, you can download QSuper's Your Privacy factsheet from our website. Alternatively, call us and we'll send you a copy. 13/6 © QSuper Board of Trustees 2012 5/5

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Statutory Declaration (Part 2)

Please complete in dark blue or black ink.

What do I use this form for?

This statutory declaration needs to be witnessed by a justice of the peace, commissioner for declarations, lawyer or notary public. A QSuper officer who is not qualified as one of the above is not able to act as a witness to this statutory declaration.

Insert the name, address, and occupation of persons making the declaration.1 I, of State occupation Postcode

do solemnly and sincerely declare the information provided by me in the application attached to this statutory declaration is true and correct. I also declare I am: under age 55, meet the 26 weeks income support requirements, and am unable to meet my reasonable and immediate living expenses from my current income and assets, and that I am not applying for a similar payment from another fund, or age 55 or over, meet the 26 weeks income support requirements, and am unable to meet my reasonable and immediate living expenses from my current income and assets, and that I am not applying for a similar payment from another fund, or age 55 and 39 weeks or over, meet the 39 weeks income support requirements, and am not gainfully employed on a full-time or part-time basis on the date of my application. I make this solemn declaration by virtue of the Statutory Declaration Act 1959, as amended, and subject to the penalties provided in the Act for the making of false statements in statutory declarations, conscientiously believing the statements contained in the declaration to be true in every particular.

Signature of person making the declaration.

Declared at

on (dd/mm/yyyy)

before me,

Signature of person before whom the declaration is made (refer to page 8 of the attached guide).

Insert the name, qualifications and address of the person before whom the declaration is made.

1 A person who wilfully makes a false statement in a statutory declaration under the Statutory Declaration Act 1959, as amended, is guilty of an offence against this Act, the punishment for which is a fine not exceeding $200 or imprisonment for a term not exceeding six months, or both, if the offence is prosecuted summarily, or imprisonment for a term not exceeding four years if the offence is prosecuted upon indictment.

Continued over page

1/2

Contact Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Telephone 1300 360 750 (+61 7 3239 1004 if overseas) Monday ­ Friday 8.30am to 5.00pm AEST

Postal address GPO Box 200 Brisbane Qld 4001 Fax 1300 242 070 Website qsuper.qld.gov.au

ABN: 60 905 115 063 SFN: 2610 419 41 5752 07/12 IB06

This document is issued by the Board of Trustees of the State Public Sector Superannuation Scheme (ABN 32 125 059 006) (QSuper Board). All products are issued by the QSuper Board as trustee for the QSuper Fund (ABN 60 905 115 063). The privacy of your personal information is important to us. QSuper Limited (ABN 50 125 248 286, AFSL 334546) is collecting this information on behalf of the QSuper Board to administer your superannuation account. This is authorised under the Superannuation (State Public Sector) Act 1990. This information may be disclosed to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies. QSuper may also disclose this information to third parties if it is necessary in providing our products and services to you, or you have consented to the disclosure, or disclosure is required by law. If you would like further information about our privacy policy, you can download QSuper's Your Privacy factsheet from our website. Alternatively, call us and we'll send you a copy. 16/6 2/2 © QSuper Board of Trustees 2012

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Contact Centres 70 Eagle Street Brisbane 63 George Street Brisbane Ph 1300 360 750 (+617 3239 1004 if overseas) Fax 1300 241 602 (+617 3239 1111 if overseas)

IB06 | 5752| 07/2012

Monday to Friday 8.30am to 5.00pm AEST GPO Box 200 Brisbane Qld 4001

qsuper.qld.gov.au

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