Mlc Statutory Form – Fill Out and Use This PDF

A DECEASED MEMBER'S DETAILS

Policy number / Member number

Mr		Mrs		Miss		Ms		Dr		Other
Surname (Family name) (PLEASE PRINT)

Given Name(s) (PLEASE PRINT)

Address

				Postcode
Date of Birth			Date of Death
/	/		/	/

1What was the deceased's marital status at the date of death?

Married		Married but separated
Divorced		Never married
Widowed		De-facto

2If the deceased was living in a relationship at the date of death, what was the duration of the relationship?

Years Months Name of spouse/de-facto

Address

Postcode

3Were there any matters pending in the Family Court between the deceased and their spouse?

No Yes

4Did the deceased leave a will? No

Yes

Please provide a certified copy of the Will.

5Please provide deceased's or Estate's tax file number

Deceased

OR Estate

B NOTIFICATION OF POTENTIAL BENEFICIARIES

Please provide details of:

•spouse (including current spouse, separated spouse, de facto spouse, ex spouse and/or same sex partner)

•child (regardless of age) including a step, adopted or ex nuptial child

•a person in an interdependency relationship

•any other person either wholly or partially dependent financially on the deceased at the time of death.

	Name		Telephone/Mobile
	Address
		Postcode
	Relationship			Date of birth
				/	/
	Name		Telephone/Mobile
	Address
		Postcode
	Relationship			Date of birth
				/	/
	Name		Telephone/Mobile

Address

	Postcode
Relationship			Date of birth
			/	/

Please attach document if additional space required

Page 1 of 4 Potential Beneficiary Statutory Declaration

C SUBMISSION – MY DETAILS

Mr

Mrs

Miss

Ms

Dr

Other

Surname (Family name) (PLEASE PRINT)

Given Name(s) (PLEASE PRINT)

Address

Postcode

Relationship to Deceased

(spouse / child / financial dependant / interdependant / legal personal representative)

Date of Birth		Telephone/Mobile number
/	/		(	)
Occupation

Email address

1Claims Details

I do not wish to be considered as a Potential Beneficiary

Go to Question 7

I wish to claim		%	of the benefit − Please complete
			the remaining sections
			on behalf of the Estate as Legal
I wish to claim		%
			Personal Representative −
			Please complete Question 7
			and Sections D and E

2I was a student at the time of death No

Yes		Part time		Full time

3I was employed at the time of death No

Yes		Part time		Weekly wage
					$
		Full time		Weekly wage	$

4I was receiving a Government Benefit at the time of death No

Yes

$

5I was living with the deceased at the time of death

No			Please provide details, eg. spouse but separated, full-time
			student living away from home and list people living with
			the deceased at the date of death

Yes	Please list people living with deceased at the time of death

6State the nature and duration of your relationship to the deceased and information regarding any dependency on the deceased. Supporting documents should be attached to evidence the dependency relationship eg. joint bank accounts, shared living expenses, joint liabilities.

I wish to be considered for the following reasons:

Please attach document if additional space required.

7I would not object to the proceeds being paid to:

Legal Personal Representative of the Deceased

Other (Please provide details below)

Name and address of beneficiary

	Postcode
Relationship	Portion of total benefit
	%

D DECLARATION

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959 (Cwlth), and I believe that the statements in this declaration are true in every particular.

Name of person making the declaration

Signature

✗	Date	/	/
Declared at (Place Declared)

on (Date Declared)

/ /

Before me,

Person before whom the declaration is made

Signature of person before whom the declaration is made

✗	Date / /

Full name and qualification of person before whom the declaration is made (PLEASE PRINT)

Address of person before whom the declaration is made

Postcode

Refer to page 4 for a list of persons before whom a statutory declaration may be made.

E LEGAL PERSONAL REPRESENTATIVE COMPLETION ONLY

Executors/Administrators completion only (if applicable)

Has a grant of Probate or a grant of Letters of Administration been received or applied for?

No			Please provide reasons below as to why an application has or will
			not be made:

Yes Please attach certified copy.

I was granted Probate / Letters of Administration on the Estate of the late

Name of deceased (PLEASE PRINT)

Date of Probate / Letters of Administration

/ /

I declare that the Estate is solvent and has sufficient assets, apart from the superannuation death benefit, to cover all liabilities of the Estate.

No

Yes

I will ensure that all proceeds from the superannuation lump sum death benefit which is paid in favour of the Estate, from The Universal Super Scheme (TUSS), will be paid in its entirety, to all or any of the persons below, being a spouse, former spouse or child of the deceased at the time of death.

No

Yes

Please list full name of beneficiary receiving superannuation death benefit

(PLEASE PRINT)

Signature of Legal Personal Representative

✗	Date	/	/
Declared at (Place Declared)

on (Date Declared)

/ /

Before me,

Person before whom the declaration is made

Signature of person before whom the declaration is made

✗	Date	/	/
Part E continued...

ELEGAL PERSONAL REPRESENTATIVE COMPLETION ONLY CONTINUED

Full name and qualification of person before whom the declaration is made (PLEASE PRINT)

Address of person before whom the declaration is made

Postcode

Note 1: A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years—see section 11 of the Statutory Declarations Act 1959 (Cwlth).

Note 2: Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959—see section 5A of the Statutory Declarations Act 1959 (Cwlth).

A Statutory Declaration under the Statutory Declarations Act 1959 (Cwlth) may be made before:

(1)A person who is currently licensed or registered under a law to practice in one of the following occupations: Chiropractor, Dentist, Legal Practitioner, Medical Practitioner, Nurse, Optometrist, Patent Attorney, Pharmacist, Physiotherapist, Psychologist, Trade Marks Attorney, Veterinary Surgeon.

(2)A person who is enrolled on the roll of the Supreme Court of the State or Territory, Or the High Court of Australia, as a legal Practitioner (However described); or A Person on the following list:

•Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public

•Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)

•Bailiff

•Bank officer with 5 or more continuous years of service

•Building society officer with 5 or more years of continuous service

•Chief executive officer of a Commonwealth court

•Clerk of a court

•Commissioner for Affidavits

•Commissioner for Declarations

•Credit union officer with 5 or more years of continuous service

•Employee of the Australian Trade Commission who is:

(a)in a country or place outside Australia; and

(b)authorised under paragraph 3 (d) of the Consular Fees Act 1955; and

(c)exercising his or her function in that place

•Employee of the Commonwealth who is:

(a)in a country or place outside Australia; and

(b)authorised under paragraph 3 (c) of the Consular Fees Act 1955; and

(c)exercising his or her function in that place

•Fellow of the National Tax Accountants’ Association

•Finance company officer with 5 or more years of continuous service

•Holder of a statutory office not specified in another item in this Part

•Judge of a court

•Justice of the Peace

•Magistrate

•Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961

•Master of a court

•Member of Chartered Secretaries Australia

•Member of Engineers Australia, other than at the grade of student

•Member of the Association of Taxation and Management Accountants

•Member of the Australian Defence Force who is:

(a)an officer; or

(b)a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or

(c)a warrant officer within the meaning of that Act

•Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants

•Member of:

(a)the Parliament of the Commonwealth; or

(b)the Parliament of a State; or

(c)a Territory legislature; or

(d)a local government authority of a State or Territory

•Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961

•Notary public

•Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal services to the public

•Permanent employee of:

(a)the Commonwealth or a Commonwealth authority; or

(b)a State or Territory or a State or Territory authority; or

(c)a local government authority; with 5 or more years of continuous service who is not specified in another item in this Part

•Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made

•Police officer

•Registrar, or Deputy Registrar, of a court

•Senior Executive Service employee of:

(a)the Commonwealth or a Commonwealth authority; or

(b)a State or Territory or a State or Territory authority

•Sheriff

•Sheriff’s officer

•Teacher employed on a full-time basis at a school or tertiary education institution

•Member of the Australasian Institute of Mining and Metallurgy

How to contact us

MLC Client Service Centre

If you have any questions, please contact your financial adviser, or the MLC Client Service Centre on 132 652 between 8.00 am and 6.00 pm (AEST/AEDT) Monday to Friday.

Return this form and any attachments to:

Trustee Services	Website
PO Box 1585	For details on MLC’s range of products
North Sydney NSW 2059	and services visit: mlc.com.au
Fax: 02 9966 3502

71323M0310