Mo014 Form – Fill Out and Use This PDF

Purpose of this form

Use this form to advise the Australian Government Department of Human Services (Human Services) if you need an early release of your superannuation to pay for medical treatment, dental treatment or transport expenses. You may be eligible if:

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•฀

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What you need to do

•฀ Read all the information provided with this application. •฀ Complete this application.

•฀ Sign and date this application.

•฀ Provide 100 points of certified identification.

•฀ Provide information listed in the checklist on page 10.

If you do not provide us with proof of identity and all relevant supporting documents, your application may be declined.

The final decision to release your superannuation early, rests with the trustee of your superannuation fund(s). You must contact your superannuation fund(s) to confirm they will release your superannuation if this application is approved.

Proof of identity

You must prove your identity by providing 100 points of certified identification. All documents supplied need to be clearly certified copies. Do not send originals. Each identification document has a different point value and you need to provide documents which add up to 100 points.

For examples of who can certify documents and a list of acceptable forms of identification and their point value go to our website

humanservices.gov.au/earlysuper

Documentation from medical practitioner and medical specialist

In addition to your application you must provide 2 separate reports of the Early Release of Superannuation on Specified Grounds – Report by Medical or Dental Practitioner and/or Specialist form (MO017).

One report must be completed by a registered medical practitioner, and the other report must be completed by the relevant registered medical specialist.

Reports need to be signed, dated and be no older than 6 months from the date of this application.

Documentation for medical treatment

Your medical/dental practitioner and medical/dental specialist each need to confirm in writing that you or your dependant require treatment for:

•฀

•฀

•฀

•฀

For an information guide to assist medical practitioners go to our website humanservices.gov.au/earlysuper

Depending on your circumstances we may need to request additional information to make a decision on your application.

Documentation for medical transport

Your medical practitioner and medical specialist each need to confirm in writing that you or your dependant require treatment for: •฀ •฀ •฀

one of your medical practitioners needs to also confirm in writing that:

•฀

•฀

•฀

•฀

•฀

For an information guide to assist medical practitioners go to our website humanservices.gov.au/earlysuper

Depending on your circumstances we may need to request additional information to make a decision on your application.

Evidence of dependency

Where you are applying for early release of superannuation to meet expenses for another person, you must prove that they are dependent on you for financial, domestic, personal or medical care. If they are your partner or child, they are considered your dependant.

Examples of evidence of dependency could include bank statements showing you provide financial support or medical certification confirming you provide personal, domestic or medical care to the person.

Depending on your circumstances we may need to request additional information.

Quotes and/or invoices

You must provide evidence of all of the medical expenses that you are applying for. Any medical expenses which are not supported by quotes or unpaid invoices from service providers will not be considered. Quotes and/or invoices need to be provided if you are applying for either medical or transport.

Quotes can be no older than 6 months from the date of this application. Unpaid invoices can be no older than 30 days from the date of this application.

The maximum release that can be considered is 12 months of medical treatment. After this period, you can re-apply.

If you are applying to purchase a vehicle for medical transport purposes you need to provide a quote for the type of vehicle you need to buy to access medical treatment. If you already have a vehicle, you need to provide confirmation of the trade in value from a relevant service provider or online vehicle pricing service.

Superannuation fund details

Important: Make sure that accessing your superannuation is the right financial option for you. The amount of superannuation you receive may be included in your taxable income, which can impact your financial situation. We recommend that you get independent financial advice before making an application for an early release of your superannuation.

For example: If you or a dependant receives a Centrelink payment, an early release of your superannuation may affect this payment.

We require the exact details relating to your superannuation fund(s) in order to process your application. Failure to provide the correct details will result in delays in processing your application.

The best way to obtain the correct details is to contact your fund(s) directly.

Your superannuation fund may deduct additional amounts for tax purposes when releasing your superannuation early. Different tax rules apply depending on your age. For more information, contact your superannuation fund or the Australian Taxation Office.

We cannot approve a release of superannuation from an Exempt Public Sector Superannuation Scheme (EPSSS). These types of superannuation funds are regulated under state and territory law.

Example:

Full superannuation fund name

SUNSUPER SUPERANNUATION FUND

Member number

003543179

Fund ABN

98 503 137 921

Registrable Superannuation Entity (RSE) number

This number is available on your fund’s website, in the Product Disclosure Statement or on correspondence sent to you by your fund. You can also obtain this information by contacting your fund.

R1000377

Exact fund balance as of today’s date

$54,562.36

The amount you want to withdraw from this fund.

This amount is a guide to assist with the assessment of your application. This amount is not an indication of how much may be released if your application is approved.

$24,000.00

Joint applications

Joint applications can be made if you and another person need to pay for the same expense(s). If you are making a joint application, each person will need to complete and submit their application forms. Both applications need to be submitted at the same time.

What we will do

Assess your application

•฀ Depending on your circumstances, we may need to request additional information to make a decision.

•฀ We will determine if you satisfy legal requirements for an early release of superannuation, by confirming that you:

a)meet one of the compassionate grounds listed in Regulation 6.19A of the Superannuation Industry (Supervision) Regulations 1994 and Regulation 4.22A of the Retirement Savings Accounts Regulations 1997, and

b)have provided all relevant supporting documentation, and

c)do not have the financial capacity to pay for the expense(s).

Outcome of assessment

•฀ You will be notified of the outcome of all assessments in writing.

•฀ There are 3 assessment outcomes. We can request more information, approve or decline your application.

–If more information is requested, you have 28 days to provide the requested information.

–If your application is approved, your superannuation fund trustee will make the final decision about whether to release your superannuation.

–If your application is declined you will be sent a letter.

Requesting a review of a decision

•฀ If you believe that the wrong decision was made on your application, you can request a review. You will need to complete an Early Release of Superannuation on Specified

Compassionate Grounds – Request for review of a decision form (MO019).

•฀ Your application will be reviewed by an employee of Human Services, who was not involved in the original decision.

Reviews must be requested within 28 days from the date on your decision letter.

For more information

For more information go to our website humanservices.gov.au/earlysuper or for assistance completing this form call 1300 131 060 Monday to Friday, between 9.00 am and 5.00 pm Australian Eastern Standard Time.

Note: Call charges apply – calls from mobile phones may be charged at a higher rate.

Filling in this form

•฀ Please use black or blue pen
•฀ Print in BLOCK LETTERS
•฀	Mark boxes like this	with a ✓ or 7
•฀	Where you see a box like this		Go to 5 skip to the question
	number shown. You do not need to answer the questions in
	between.

Returning your form

Check that you have answered all the questions you need to answer and that you have signed and dated this form.

Send the completed form and all supporting documentation to:

Department of Human Services

ERSB Programme

PO Box 1001

TUGGERANONG DC ACT 2901

or

Scan and email: ERSBenquiries@humanservices.gov.au

Applicant’s details

1Dr Mr Mrs Miss Ms Other Family name

First given name

Other given name(s)

Previous name(s) (if applicable)

2Date of birth

//

3Your sex Male

Female

4Address

Postcode

5Postal address (if different to above)

Postcode

6Home phone number

( )

Work phone number

()

Mobile phone number

Email

@

7What is your residency status? Australian citizen

New Zealand citizen

Permanent Australian resident

Temporary Australian resident

Other Give details

Australian and New Zealand citizens, permanent residents of Australia or holders of a retirement visa (subclass 405 or 410) are eligible to apply for an early release of superannuation on compassionate grounds. If you are visiting Australia on a temporary visa (excluding subclasses 405 and 410), you may not be eligible for the early release of your superannuation on compassionate grounds. Contact the Australian Taxation Office for further information.

Superannuation fund(s)

Contact your superannuation fund to obtain your superannuation account(s) current balance.

8Superannuation fund 1

Full superannuation fund name

Member number

Fund ABN

Registrable Superannuation Entity (RSE) number.

This number is available on your fund’s website, in the Product Disclosure Statement or on correspondence sent to you by your fund. You can also obtain this information by contacting your fund.

R

Exact gross fund balance as of today’s date

$

The amount you want to withdraw from this fund.

This amount is a guide to assist with the assessment of your application. This amount is not an indication of how much may be released if your application is approved.

$

Superannuation fund 2

Full superannuation fund name

Member number

Fund ABN

Registrable Superannuation Entity (RSE) number.

This number is available on your fund’s website, in the Product Disclosure Statement or on correspondence sent to you by your fund. You can also obtain this information by contacting your fund.

R

Exact gross fund balance as of today’s date

$

The amount you want to withdraw from this fund.

This amount is a guide to assist with the assessment of your application. This amount is not an indication of how much may be released if your application is approved.

$

If additional superannuation funds need to be listed, attach a separate sheet with details.

Employment and income

9Are you employed?

Employment can mean full time, part time or casual work for which you are paid

No Go to 12

Yes

10On what basis are you employed? Permanent – full or part time

Temporary

Casual

Other Give details

11What is your income from employment after tax?

$

Weekly

Fortnightly

Monthly

12Are you receiving a Commonwealth Income Support Payment (e.g. Centrelink benefits)?

No Go to 14

Yes

13What is your income from Support Payments?

$

Weekly

Fortnightly

Monthly

14Do you receive income from any other source?

No Go to 17

Yes

15Where do you receive the income from (e.g. from investment properties or shares)?

16How much do you receive?

$

Weekly

Fortnightly

Monthly

17Do you have a partner?

No Go to 27

Yes

18Your partner’s full name

19Is your partner employed?

Employment can mean full time, part time or casual work for which your partner is paid.

No Go to 22

Yes

20On what basis is your partner employed? Permanent – full or part time

Temporary

Casual

Other Give details

21What is your partner’s income from employment after tax?

$

Weekly

Fortnightly

Monthly

22Is your partner receiving a Commonwealth Income Support Payment (e.g. Centrelink benefits)?

No Go to 24

Yes

23What is your partner’s income from Support Payments?

$

Weekly

Fortnightly

Monthly

24Does your partner receive income from any other source?

No Go to 27

Yes

25Where does your partner receive the income from (e.g. from investment properties or shares)?

26How much does your partner receive?

$

Weekly

Fortnightly

Monthly

27Do any other members of your household contribute towards household costs?

No Go to 30

Yes

28How much do they contribute?

$

Weekly

Fortnightly

Monthly

29Relationship to you

Assets

30Do you own property, other than the home where you live (e.g. investment properties or land)?

No
Yes	What is the value of properties you own other than
	the property where you live?
	$

31Do you hold shares or other investments?

No
Yes	What is their value?
	$

32What is the estimated value of your household goods?

$

33Have you received funding from the National Disability Insurance Scheme?

No

Yes Give details Funding received

$

Current balance

$

34Please read this before answering questions 34 and 35.

Do not include accounts used exclusively for funding from the National Disability Insurance Scheme.

What is the combined value of money you and your partner hold in transaction accounts (e.g. the account that you use to pay bills and day to day expenses)?

$

35What is the combined value of money you and your partner hold in savings accounts (e.g. amounts in term deposits, long term savings accounts, etc)?

$

36Do you and/or your partner own a motor vehicle(s)?

No Go to 39

Yes

37How many vehicles do you and/or your partner own?

38Total estimated value of vehicle(s)

$

39Estimate the value of other assets you own (e.g. collectable items, caravans, boats, etc)

Asset 1

Current market value

(The current market value of an item is what you would get if you sold it. It is not the replacement or insured value.)

$

Asset 2

Current market value

(The current market value of an item is what you would get if you sold it. It is not the replacement or insured value.)

$

If additional assets need to be listed, attach a separate sheet with details.

Liabilities

40Do you and/or your partner have any loans with financial institutions or outstanding debts (e.g. debts to Centrelink, the Australian Taxation Office, loans from family etc)?

No Go to 44

Yes

41How many loans/debts do you and/or your partner have?

42What types of loans/debts do you and/or your partner have?

Home loan

Business loan

Personal loan

Vehicle loan

Line of credit

Overdraft

Investment loan

Centrelink debt

Australian Taxation Office debt

Loan from third party

Other Give details

43What is the total monthly loan/debt repayment amount for your and/or your partner’s loan(s)?

$

44Do you and/or your partner have any credit cards including store cards?

No Go to 49

Yes

45How many credit cards do you and/or your partner have?

46What is the total balance owing on your and/or your partner’s credit card(s)?

$

47What is the total credit limit of your and/or your partner’s credit card(s)?

$

48What is the total monthly credit card repayment amount for your and/or your partner’s credit card(s)?

$

49Are you currently registered as bankrupt?

No
Yes	Attach a letter from your trustee which
	confirms that a release of your
	superannuation will be exempt from
	assessment under your bankruptcy
	agreement.

Household expenses

This information must be accurate. You may be asked to supply further information to support your application.

You need to record your monthly household expenses. If you pay your expenses:

•฀ weekly you need to multiply the expense by 4.333 For example: $200 x 4.333 = $ 866.60

•฀ fortnightly you need to multiply the expense by 2.167 For example: $200 x 2.167 = $433.40

•฀ quarterly you need to divide the expense by 3 For example: $4000 divided by 3 = $1,333.33

50What are your monthly household expenses?

Please complete all fields. Where an expense is not applicable, please write $0

a)Rent/Board (this does not include home or investment loan repayments)

$

b)Groceries

$

c)Electricity

$

d)Gas

$

e)Mobile phones

$

f)Home phone and internet

$

g)Water

$

h)Land rates

$

i)Medical expenses

$

j)Transportation

$

k)Insurance

$

l)Child care

$

m)School fees

$

n)Other expenses (Give details)

$

Dependants

51Do you have any dependants? Your dependants are:

•฀ your partner or spouse

•฀ your children (if they are not living independently from you) •฀ anyone else who is dependent on you for financial,

domestic or personal support (e.g. an elderly parent who lives with you).

No

Yes Give details

Dependant 1

Family name

First given name

Age

Relationship to you

Dependant 2

Family name

First given name

Age

Relationship to you

If additional dependants need to be listed, attach a separate sheet with details.

Joint applications

52Is another person applying with you for the early release of superannuation to pay for the same expenses?

No Go to 56

Yes

53Other applicant’s full name

54Can we contact the other applicant to discuss your application? No

Yes

This information will assist in processing your application and reduce any unnecessary delays.

55Do we have permission to speak with the other applicant if they call us?

No Yes

Medical or dental treatment

56Are you claiming for medical or dental treatment expenses?

No Go to 61

Yes

57Who requires the medical or dental treatment for which you are applying?

You

Your dependant Give details

Dependant

Family name

First given name

Relationship to you

If additional dependants need to be listed, attach a separate sheet with details.

58Do you or your dependant have an existing worker’s compensation claim relating to this condition?

No
Yes	Please attach claim details that show which
	treatment expenses are, or are not, covered
	by the worker’s compensation claim.

59Identify what the expense(s) you are applying for relate to

Ongoing treatment (e.g. physiotherapy, psychiatric treatment, etc

Surgery

Medication

Dental treatment

Other Give details

60Do you have private health cover which will assist with any or all of these costs?

No
Yes	Please attach health cover rebate details.

Medical or dental transport

61Are you applying for the cost of transport to access treatment?

No Go to 67

Yes

62Who needs the treatment for which you are claiming transport costs?

You

Your dependant Give details

Dependant

Family name

First given name

Relationship to you

If additional dependants need to be listed, attach a separate sheet with details.

63Do you or your dependant have an existing worker’s compensation claim relating to this condition?

No
Yes	Please attach claim details that show which
	transport expenses are or are not covered
	by the worker’s compensation claim.

64Identify what the expense(s) you are applying for relate to Purchase of a vehicle

Repairs to an existing vehicle

Running costs of a vehicle

Use of public transport

Flights

Other Give details

65Are you applying to purchase a vehicle to access medical treatment?

No Go to 67

Yes

66Do you or your dependant have a motor vehicle?

No
Yes		Please explain why the existing vehicle cannot be
		used

You must attach evidence of the trade in value of your existing vehicle(s).

Additional information

67Did you tick No to both questions 56 and 61?

No
Yes	If you ticked No to both questions 56 and 61 your
	application could be declined.

68Provide any additional information relevant to your application

If you need to provide more information, attach a separate sheet with details.

Permissions

69Do you want another person(s) or organisation(s) to enquire or act on your behalf when dealing with us?

No Go to 71

Yes

70Name any person(s) or organisation(s) we can discuss your application with. This could be your spouse, child or superannuation fund.

Person 1

Name

Contact phone number

()

Relationship to you

Person 2

Name

Contact phone number

()

Relationship to you

Person 3

Name

Contact phone number

()

Relationship to you

If any person(s) or organisation(s) listed hold a Power of Attorney, attach a certified copy.

Checklist

If you do not provide us with the relevant supporting documents, your application may be declined.

71Indicate which supporting documents you are attaching with your application

100 points of certified identification (refer to Proof of identity page 1)

Report from medical practitioner (refer to Documentation for medical treatment page 1)

OR

Report from medical practitioner (refer to Documentation for medical transport page 1)

AND

Report from medical specialist (refer to Documentation for medical treatment page 1)

OR

Report from medical specialist (refer to Documentation for medical transport page 1)

Evidence of dependency (refer to Evidence of dependency page 1)

Quotes and/or invoices for total cost of medical treatment or transport (refer to Quotes and/or invoices page 1)

Superannuation fund details (make sure you have completed question 8)

A Power of Attorney if appropriate (refer to question 70)

Additional information that may have been requested in the application form

Privacy notice

72Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim.

Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law.

You can get more information about the way in which the Department of Human Services will manage your personal information, including our privacy policy at humanservices.gov.au/privacy or by requesting a copy from the department.

Declaration

73I declare that:

•฀ the information I have provided in this form is complete and correct.

•฀ I have attached the relevant supporting documentation and certified copies of evidence of identity for this application.

I understand that:

•฀ giving false or misleading information is a serious offence. I authorise:

•฀ the person(s) or organisation(s) named in this application at question 70 to act or enquire on my behalf.

Applicant’s signature

-

Date

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