Withdrawal Form (for cash only withdrawals)

Withdrawal Form (for cash only withdrawals)
For Accumulation Plan, Beneficiary Account and Income Stream members
Who should use this form?
You should use this form if you are a member of the Accumulation Plan, Beneficiary Account or Income Stream and want to make a cash
withdrawal from your account. If you want to rollover money to another super fund, or to another ESSSuperproduct you should complete
the Withdrawal Form (for Cash and Rollover Withdrawals) – form ES164. If you are terminating employment with an emergency services
employer and want to claim your benefit, please complete the Application for Superannuation Benefit form instead, available from our
Member Service Centre. For any term deposit investments, no withdrawal is permitted prior to maturity.
Please complete this form in pen using CAPITAL letters and mark with an [ ] where applicable.
Section 1
Your personal details
Member/Pension no.
Other (please specify)
Given names
Date of birth
Postal address
Mark with an [ ] if your postal and residential address are the same. If your residential address is different, please specify below.
Residential address
Telephone (business hours) (
Telephone (mobile)
If you are a temporary
resident, please tick box
Section 3
I declare that I am:
(after hours) (
Note: If you are a temporary resident, restrictions may apply. ESSSuper will notify you if restrictions apply to this withdrawal.
Section 2
I am making this
withdrawal from the
following account:
Account details
Accumulation Plan*
Beneficiary Account
Working Income Stream*
Retirement Income Stream*
No term deposit withdrawals prior to maturity.
Employment status
Permanently retired from the workforce
(i.e. working less than 10 hours a week)
Not permanently retired from the workforce
Issued by: Emergency Services Superannuation Board ABN 28 161 296 741 as Trustee of the Emergency Services Superannuation Scheme ABN 85 894 637 037
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Withdrawal Form (for cash only withdrawals) For Accumulation Plan, Beneficiary Account and Income Stream membersES163
Section 4
Payment details
Partial withdrawal
Full withdrawal (and close account)
Net amount to
be withdrawn
(This is the amount after tax has been deducted, if applicable)
Amount in words
Name of financial
Account holder name
(e.g. John Citizen)
BSB number
Account number
The account must be in the member’s name or a joint account including the member’s name. If as a result of this
withdrawal, your account balance falls below $5,000, ESSSupermay require you to withdraw your total balance.
For Accumulation Plan and Beneficiary Account members, a minimum withdrawal of $1,500 after tax applies.
Section 5
Certified Identification
If this is your first withdrawal to the bank account you nominated in SECTION 4, you are required to provide a
certified copy of your identification. Certified copies are copies of original documents that have been verified
and signed by one of the professional persons listed below. Certified copies provided must contain the original
signature and cannot be a photocopy, scanned copy via email or facsimile. For all subsequent withdrawals to the
same account, you will not be required to provide certified identification. For Income Stream members, certified
identification is not required if the bank account you have nominated is the same account as for your regular
income payments.
Please provide either:
Option 1: Current Driver’s Licence or Passport
Option 2: Either a birth certificate or extract,
Australian citizenship certificate
OR Centrelink pension card.
A letter addressed to you from Centrelink
regarding a benefit payment, a letter from a
Federal, State or local government body showing
your name and residential address, e.g. rates
notice OR a Tax Office Notice of Assessment.
If you have changed your name or are signing on behalf of the applicant, you will need to provide a certified linking
document – a linking document is a document that proves a relationship exists between two (or more) names.
The following table contains information about suitable linking documents:
Suitable linking documents
Change of name
Marriage certificate, deed poll or change of name certificate
from the Births, Deaths and Marriages Registration Office
Signed on behalf of the applicant
Guardianship papers or Power of Attorney
Note: Key persons who can certify documents include (but are not limited to) an Accountant, Bank Officer, Justice of the
Peace, Police Officer, Full-time Teacher or Medical Practitioner. For a full list, please call our Member Service Centre.
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Withdrawal Form (for cash only withdrawals) For Accumulation Plan, Beneficiary Account and Income Stream membersES163
Section 6
Declaration and signature
I acknowledge and
agree that:
•• I have read and understood the Product Disclosure Statement relevant to my superannuation benefit
which is available from ESSSuper and I understand the tax and investment implications of this withdrawal.
•• For Beneficiary Account and Income Stream members - This withdrawal will reduce my investment option
balances based on the default order (i.e. Cash, Defensive, Conservative, Balanced, Growth, High Growth,
Shares Only), unless I request otherwise.
•• For Beneficiary Account members - my previous employment with my emergency services employer did not
cease whilst suffering from disability or ill health (as defined under the Emergency Services Superannuation Act 1986).
•• If I have requested an investment option change, my withdrawal may not be processed within the first 10
days of the month that my investment options change takes effect (e.g. if your investment options change
takes effect from 1 July, your withdrawal may not be processed until 11 July).
•• I have considered obtaining independent financial advice with respect to my superannuation options.
Signature of
account holder
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
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