Form 6 (Declaration) and Application for Information

ES133
Form 6 (Declaration) and Application
for Information
Who should use this form?
You should complete this form if you are seeking information regarding a superannuation interest for Family Law matters. You must be
a member, or a spouse (from 1 March 2009 this includes de facto spouse and same sex relationships) of a member who has an interest in
a fund administered by ESSSuper (including the ESSS Defined Benefit Fund, Accumulation Plan (also known as ESSPLAN Accumulation
Fund), Beneficiary Account, Retirement or Working Income Streams, New Scheme, Revised Scheme, SERB Scheme, Melbourne Water
Corporation Employees’ Superannuation Scheme, Port of Melbourne Authority Superannuation Scheme, Melbourne Transit Authority
Superannuation Scheme and Transport Scheme).
You should not complete this form if you are a legal representative or financial advisor acting on behalf of a member or spouse. Section
90 MZB (8) of the Commonwealth Family Law Act 1975 determines who an eligible person is. Please contact us for further information.
Before you start
Prior to submitting your Form 6 Declaration (Part A) and Application for Information (Part B) please ensure you have read the Family Law
Information Sheet. The Family Law Information Sheet has been designed to help you understand the Family Law provisions and it contains
information that will help you complete this form, as well as providing important information about the legislation and regulations that
guide ESSSuper in Family Law matters.
You will need to complete all sections of Part A and Part B (excluding those marked optional) for this form to be valid.
If you are unsure of the options available to you or would like any further information on Family Law please call our Member Service
Centre and ask to speak with a Family Law Administrator prior to submitting your application.
Please complete this form in pen using CAPITAL letters and mark with an [ ] where applicable.
Part A
Form 6 (Declaration)
Section 1
Your declaration
I, (full name)
of (postal address)
Suburb
State
Postcode
/
Date of birth
/
make the following declaration in support of my application to the trustee of ESSSuper (the Fund) for information
about: (mark with an [ ] where applicable)
My superannuation interest
OR
The superannuation interest of:
Title
Mr
Mrs
Ms
Miss
Other
(please specify)
Surname
Given names
Date of birth
/
/
who is a member of the Fund.
Issued by: Emergency Services Superannuation Board ABN 28 161 296 741 as Trustee of the Emergency Services Superannuation Scheme ABN 85 894 637 037
May 2015 1 of 3
Form 6 (Declaration) and Application for Information
Section 2
You must select
at least one of the
options listed for
your form to be valid.
ES133
The purpose of your application
I am: (mark with an [ ] where applicable)
A member of the Fund.
OR
The spouse of: (member’s full name)
who is a member of the Fund.
OR
Intending to enter into a superannuation agreement under Part VIIIB of the Family Law Act 1975 with:
(member’s full name)
who is a member of the Fund.
Section 3
You must select
at least one of the
options listed for
your form to be valid.
The reason you require the information
I require the information to: (mark with an [ ] where applicable)
Assist me to properly negotiate a superannuation agreement.
OR
Assist me in connection with the operation of Part VIIIB of the Family Law Act 1975.
Part B
Application for information
Section 1
Where you wish to have the information sent
If you wish to have
the information
sent to your legal
or Financial Advisor
or to any address
other than the address
you provided in
PART A - you should
complete the details
in this section.
I request that the information be sent to:
My postal address as provided in PART A (Section 1).
OR
To the following postal address:
Name
Address
Suburb
State
Section 2
Postcode
(Optional) The date(s) you wish to have the information provided at
Please provide me with information at the following dates: (you can specify up to 3 dates in this application)*
First appropriate date:
/
/
Second appropriate date:
/
/
Third appropriate date:
/
/
Note: The information will be provided at the “appropriate date(s)”. If not specified, the “appropriate date” of this application
is defined under Regulation 61 to be the date on which ESSSuper receives your application.
* Please refer to the Information Sheet (Section 4 “Fee schedule”) for information on the fee structure.
May 2015 2 of 3
Form 6 (Declaration) and Application for Information
Section 3
ES133
Supporting documents and certified identification
Please ensure you
attach the following
documents to your
Application form:
If ESSSuper does not hold a copy of your signature on file we require you to provide a certified copy* of
your current Driver’s Licence or valid passport.
Note: If you do not have a current driver’s licence or current passport please provide a certified copy* of any other photo
identification that contains your signature.
AND
If you are employing the services of a financial adviser or solicitor and you require that person to act on your
behalf during the application process then we require written authority from you. An Authority to Release
Information to Third Parties form is available from our website or by contacting us.
AND
The relevant fee for ESSSuper to process your request.
Note: Please refer to the Information Sheet (Section 4 “Fee Schedule”) to ensure that you have enclosed the appropriate fee.
If you are the
non-member
spouse we
also require:
If you are married:
A certified copy* of your marriage certificate.
If you are not married (i.e. in a de facto relationship, including same sex couples):
Certification of Registration on the Relationships Register (pursuant to the Relationships Act 2008).
OR
A Declaration by the Family Court pursuant to Section 90RD (1) of the Family Law Act 1975 as to the existence
of your de facto relationship.
OR
A Statutory Declaration as to the existence of your relationship, including information regarding the
geographical location and length of the relationship.
Note: If you are in doubt as to whether ESSSuper has your signature on file, please provide the certified copy of your photo
identification and signature to ensure there is no delay in processing your request.
* Please refer to the Family Law Information Sheet (Section 11 “How to Certify ID”) for details on what you need to do to get
copies of your ID legally certified and for details about who can certify documents.
Section 4
Declaration and signature
This Application
I declare that:
cannot be processed
•• The information contained in this form is accurate.
if it is incomplete or
the required supporting •• By signing below, I understand and consent to ESSSuper collecting and using the information contained in
this form to administer the relevant public sector superannuation scheme. I understand and consent to this
documentation has
information being used solely for the purpose of administering the relevant superannuation fund and to
not been supplied,
obtain information about a superannuation interest under the Family Law Act 1975 and related legislation and
is not certified or is
regulations. Any personal information collected by ESSSuper relating to my personal affairs will be treated in
incorrect.
accordance with the provisions of the Information Privacy Act 2000 and the Information Privacy Principles.
•• My consent is valid for the purposes of this form only.
Signature
 Please sign here
Date
/
/
Please forward this completed form to
ESSSuper GPO Box 1974, Melbourne Vic 3001
T 1300 650 161 | F 1300 766 757 | www.esssuper.com.au
At ESSSuper, we treat the privacy and confidentiality of our members’ personal information seriously. We are committed to complying with the
guidelines of the Privacy and Data Protection Act 2014 and the Health Records Act 2001 (Vic). To obtain a copy of ESSSuper’s privacy policy go to our website
at www.esssuper.com.au
May 2015 3 of 3