ESSSuper Forms Proudly serving our members

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ESSSuper Forms Proudly serving our members
ESSSuper
Forms

Proudly serving our members

We’ve put together a selection of forms                            Accumulation Plan application
you might need when opening an                                     form (E166)
ESSSuper Accumulation Plan account.
For more information, or to download                               Transfer your super (ES104)
copies of any of our forms, please visit
esssuper.com.au/forms                                              Regular contributions (ES151)
                                                                   Choice of superannuation fund
                                                                   (ES142)

Issued by: Emergency Services Superannuation Board ABN 28 161 296 741 (Board) as Trustee of the Emergency Services Superannuation
Scheme ABN 85 894 637 037 (Scheme)
This page has been left blank intentionally
E166

Accumulation Plan application form
For members and their spouses
Issued: 1 July 2021

   Please complete this form in pen using CAPITAL letters and mark with an [ ] where applicable.
    Part A                         To be completed by person joining the Accumulation Plan

    Section 1                       Your personal details

   Member number                                                                       (leave blank if you are a new ESSSuper member)

   Title                                Mr              Mrs            Ms              Miss            Other     (please specify)

   Surname

   Given names

   Date of birth                               /              /

   Postal address

                                  Suburb

                                  State                       Postcode

                                        Mark with an [ ] if your postal and residential address are the same. If your residential address is different, please specify below.

   Residential address

                                  Suburb

                                  State                       Postcode

   Telephone (business hours) (                     )                                             (after hours) (                  )

   Telephone (mobile)

   Email address
           By providing your email address, you are authorising ESSSuper to send communications including statement notifications to that address. This authorisation
           will apply until it is revoked by you. I understand I can change my communication preferences at any time by calling ESSSuper on 1300 650 161 (for emergency
           services members) or 1300 655 476 (for state super members) or through the My details/Manage preferences section of MembersOnline.

   Your main employer
   Your main occupation

   Tax File Number (TFN)                            -                    -
   ESSSuper is legally authorised to collect your TFN and will use it only for lawful purposes, including:
   • calculating tax on any super benefit to which you are entitled and providing information to the Commissioner of Taxation
   • transferring your benefit to a complying super fund, an exempt public sector super fund, or to a retirement savings account, where we may disclose your TFN
       to the Trustee or provider of that fund or account or the Commissioner of Taxation, unless you advise us in writing not to disclose it.
   You are not obliged by law to provide your TFN and it is not an offence to not quote your TFN, however, providing your TFN to ESSSuper will have the following
   advantages (which may not otherwise apply):
   • ESSSuper will be able to accept all types of contributions to your account
   • ESSSuper will be able to use your TFN to identify your account and contributions that your employer may make on your behalf
   • ensure you receive the Government co-contribution if you are eligible
   • the tax on super contributions will be at the concessional rate instead of the highest marginal tax rate (unless you make excess contributions)
   • other than the tax that may ordinarily apply, no additional tax will be deducted when you start drawing down your super benefits
   • it will be easier to trace different super accounts in your name so that you receive all of your super benefits when you retire
   • with your consent, we can check with the ATO or another super fund for any lost super you may have and arrange for any lost super to be combined into your ESSSuper account.
   If we do not have your TFN, we will not be able to accept personal contributions from you and you will pay more tax on your superannuation. The lawful purposes for
   which we can use your TFN, and the consequences of not providing your TFN, may change in the future as a result of legislative change. We may also use your TFN to
   identify multiple accounts within ESSSuper and consolidate them where permitted under law.

Issued by: Emergency Services Superannuation Board ABN 28 161 296 741 as Trustee of the Emergency Services Superannuation Scheme ABN 85 894 637 037
                                                                                                                                                                 July 2021 1 of 6
Accumulation Plan application form                                                                                                                   E166

  Section 2               Add money to your account
  Please indicate            contribute regularly from your pay – complete the enclosed Regular contributions (ES151) form and forward
  whether you want to        it to your employer, or if you are employed by the Department of Education & Training as a school-based
  (you may select more
                             staff member or principal, complete the Salary Sacrifice for DE&T members to an Accumulation Plan
  than one)
                             (via SmartSalary.com.au) form instead, available at esssuper.com.au/forms

                             transfer money from another super fund – complete and attach the enclosed Transfer your super (ES104) form

                             arrange for your employer to make superannuation guarantee (SG) contributions to your account.
                             Please read the enclosed Choice of superannuation fund (ES142) and complete and forward all relevant
                             forms to your employer.

                             arrange for ESSSuper to use your TFN to conduct regular searches of the ATO facility to locate any super you
                             have elsewhere and help you consolidate your funds.
                         Personal and spouse contributions: You will receive your BPAY details (Biller Code and Customer Reference Numbers) when
                         your account has been opened.

  Section 3               Default insurance cover

                         Section 3A
                         Default insurance cover opt-in*
                         Are you under 25 or do you have an account balance of less than $6,000?
                         • Age-based default cover (equal to 3 units of Death and TPD cover at $3.37 per week) will start when you turn
                           25 for non-operational members AND have an account balance of $6,000 or over AND your employer pays an
                           SG contribution into the Accumulation Plan within 120 days of you becoming eligible for default cover. We will
                           write to you when cover starts.
                         • If you need cover earlier, you can elect (opt-in) for default cover without health assessment within 120 days
                           of joining the Accumulation Plan. Cover will commence on the later of a) the date of this election; and b) the
                           date on which the Accumulation Plan receives the first employer contribution. Please mark the opt-in box
                           below.

                             I’d like to opt-in for default insurance cover.

                         * Cover is subject to conditions and exclusions. Please read the Insurance Guide (AP.2) available on our website at
                           esssuper.com.au/pds to determine if you are eligible for default cover. If you are ineligible for default cover or wish to
                           increase or reduce your existing cover, then complete the Vary your Insurance Cover for Accumulation Plan members form
                           (ES167) available on our website at esssuper.com.au/forms. The cost of automatic cover is $3.37 per week (i.e. $1.12 per unit
                           per week) or $175.59 per year.

                         Section 3B
                         Default insurance cover opt-out
                         If you are:
                         • a non-operational member 25 years or older AND with an account balance of $6,000 or more AND your
                           SG contributions are being paid into this fund, or
                         • a Protective Services Officer (PSO) recruit AND your SG contributions are being paid into this fund,
                         then, you are eligible to receive default cover (equal to 3 units of Death and TPD cover at $3.37 per week)
                         without having to apply for it. If you are satisfied with this default insurance, skip this section and GO TO
                         SECTION 4.
                         Alternatively, if you’d like to opt-out of default insurance cover, please mark the box below.
                             I’d like to opt-out of default insurance cover.

                         Important Notice
                         You can also apply for cover anytime after 120 days of joining the Accumulation Plan if you need cover. If you
                         wish to apply for cover, or for additional cover, then complete the Vary your Insurance Cover for Accumulation Plan
                         members form (ES167) and the Insurer’s Personal Statement available on our website at esssuper.com.au/forms

                                                                                                                                           July 2021 2 of 6
Accumulation Plan application form                                                                                                                         E166

  Section 4                       Investment choice
  Please specify your                                            Future contributions
  investment choice                                              (including rollovers)
  for your Accumulation
  Plan account                   Standard Options

                                 Shares Only                                        %

                                 High Growth                                        %

                                 Growth (DEFAULT OPTION)                            %

                                 Balanced                                           %

                                 Conservative                                       %

                                 Defensive                                          %

                                 Cash                                               %

                                 Alternative Options

                                 Basic Growth                                       %

                                 Ethically Minded                                   %

                                 Total (must equal 100%)               1    0   0 %

                                 Note: If you do not make an investment choice for future contributions, all future contributions and investment earnings on
                                 those contributions will be deposited into the default option, Growth. If you rollover a benefit from another superannuation
                                 fund or from an ESSSuper product it will be invested in the same way as your future contributions.

  Section 5                       Non-binding death benefit nomination

  Complete this section to make a non-binding death benefit nomination for your account.

  I want to nominate:
  My Estate (Legal Personal Representative)                                                                                  % of benefit                   %

  And/Or                                                                                                       If 100% do not complete section below

  If you nominated 100% to your estate, you do not need to complete this section.
  My beneficiaries listed below:

  Name of Dependant #1

  Date of birth                              /           /                                                                   % of benefit                   %

  Type of dependant                  Spouse
  (please select one box only)
                                     Child

                                     Financial dependant – if so, relationship to you

  Name of Dependant #2

  Date of birth                              /           /                                                                   % of benefit                   %

  Type of dependant                  Spouse
  (please select one box only)
                                     Child

                                     Financial dependant – if so, relationship to you

                                                                                                                                                 July 2021 3 of 6
Accumulation Plan application form                                                                                                                       E166

   Section 5                      Non-binding death benefit nomination (cont.)

  Name of Dependant #3

  Date of birth                               /           /                                                                   % of benefit                %

  Type of dependant                   Spouse
  (please select one box only)
                                      Child

                                      Financial dependant – if so, relationship to you

  Name of Dependant #4

  Date of birth                               /           /                                                                   % of benefit                %

  Type of dependant                   Spouse
  (please select one box only)
                                      Child

                                      Financial dependant – if so, relationship to you

                                                                              Total (Must equal 100% and cannot be decimals)                1    0   0   %

                                 Note: If you want to nominate more than four beneficiaries, please attach your instructions to this form.

  To make a binding death benefit nomination, complete the Binding death benefit nomination form (ES106) available from our website
  at esssuper.com.au/forms

  Section 6                       Financial Adviser authority
                                 I allow my Financial Adviser as listed below, and their staff, to access my account details for the purposes of
                                 ongoing monitoring and providing advice to me. This authority remains valid until it is revoked by me in writing.

  Adviser name

  Company

  Postal address

                                 Suburb

                                 State                    Postcode

  AFSL

  Telephone                       (               )

  Contact person
  Adviser stamp

                                                                                                                                                July 2021 4 of 6
Accumulation Plan application form                                                                                                           E166

  Section 7             Declaration by account holder
  I declare that       • I have received and read the Accumulation Plan Product Disclosure Statement (PDS) and Incorporated Guides and note the
                         taxation, investment, insurance and other implications of my election to become a member of the Accumulation Plan.
                       • I acknowledge and accept that the benefits in the ESSSuper Accumulation Plan are not guaranteed or underwritten
                         by the Victorian Government or Emergency Services Superannuation Board and that ESSSuper does not come
                         under the jurisdiction of the Australian Financial Complaints Authority.
                       • I acknowledge that all contributions and investment income will be invested in accordance with my instructions on
                         this form, and if no instructions are given, the default investment option (Growth) will apply.
                       • I have read the section relating to the insurance arrangements and my duty of disclosure within the Accumulation
                         Plan PDS and Incorporated Guides.
                       • I have not withheld any information which may affect any decision to provide insurance.
                       • I have read and accept the statements relating to privacy on page 8 of the Accumulation Plan PDS and I consent
                         to providing ESSSuper with my personal information pursuant to the Privacy and Data Protection Act 2014 for the
                         purposes described in ESSSuper’s Privacy Policy and Privacy Collection Statement available from our website at
                         esssuper.com.au
                       • I consent to ESSSuper using my TFN to locate my super by conducting regular searches of the lost super facility
                         provided by the ATO. I understand that ESSSuper will continue to do this until I revoke my consent in writing.
                       • I consent to ESSSuper providing access to my Financial Advisor and their staff in respect of my account for the
                         purposes of ongoing monitoring and providing advice to me. I understand that ESSSuper will continue to do this
                         until I revoke my consent in writing.
                       • By providing my email address, I am authorising ESSSuper to send communications via email, including statement
                         notifications, confirmation of transactions, notices of events and changes required by law to be given to members,
                         and any other communications relating to products and services offered by ESSSuper to that email address.
                       • I declare all information supplied by me in this Application form is true, correct and complete.

  Signature of          PLEASE SIGN HERE                                                   Date              /            /
  account holder

   Part B              To be completed by current ESSSuper member to open an account for your spouse

  Section 8             Personal details of current ESSSuper member
                       Only complete this section if you are applying for an account in the Accumulation Plan for your spouse. The
                       details below should be for the person who is a current ESSSuper member, not the person who is applying to
                       join the Accumulation Plan. The current ESSSuper member must also sign Section 9.

  Member number

  Title                    Mr            Mrs          Ms            Miss         Other     (please specify)

  Surname

  Given names

  Date of birth                  /             /

  Section 9             Declaration by current ESSSuper member

                       This declaration is only required to open an account for the spouse of the current ESSSuper member whose
                       details are provided in Section 8.
                       I declare that:
                       • I am currently an ESSSuper member
                       • I agree to be bound by the terms and conditions of the Emergency Services Superannuation Act 1986 (Vic)
                       • the person who is applying to join the Accumulation Plan as listed in Section 1 is my spouse or de facto
                          partner and currently lives with me on a permanent basis
                       • my spouse and I are Australian residents for tax purposes
                       • I understand that any contributions to my spouse’s account belong to my spouse.

  Signature of          PLEASE SIGN HERE                                                   Date              /            /
  current member

                                                                                                                                   July 2021 5 of 6
Accumulation Plan application form                                                                                                                           E166

              IMPORTANT: IF YOU ARE A NEW NON-OPERATIONAL EMERGENCY SERVICES EMPLOYEE PLEASE FORWARD
              YOUR COMPLETED FORM TO YOUR EMPLOYER. ALL OTHER MEMBERS SHOULD FORWARD THEIR COMPLETED
              FORM TO ESSSUPER.

  EMPLOYER USE ONLY

                               To be completed for all new non-operational emergency services employees.

  Employer name

  Employee/Payroll no.
  Date commenced                           /             /
  employment
  Occupation

                               If the employee has not provided their Tax File Number, please provide below:

  Employee’s Tax File No.                      -                   -
  Name of
  authorised officer

  Signature of                   PLEASE SIGN HERE                                                        Date               /              /
  authorised officer

                               Have you provided this employee with the Accumulation Plan Product Disclosure Statement?

                                    Yes            No

  ESSSUPER OFFICE USE ONLY

  MEC name

  Appt date                                /             /

  For DB Members only          This is a           Top-up account               Personal member account

  If you are a new operational emergency services employee, please forward your completed form to your employer.
  All other members should email the completed form to info@esssuper.com.au or post to:
  ESSSuper GPO Box 1974, Melbourne Vic 3001
  T 1300 650 161 | W 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 copies of ESSSuper’s Privacy Policy and Privacy
  Collection Statement, please visit our website at esssuper.com.au

                                                                                                                                                    July 2021 6 of 6
ES104

Transfer your super
Issued: 1 July 2021

    Before you start
   • Transferring your super from other super funds is easiest done on Members Online once you have received your personal login details,
      or you can complete this form.
   • If you are transferring into a new ESSSuper account, please also complete the application form in the relevant Product Disclosure
      Statement at esssuper.com.au/pds
   • Please post the original form to ESSSuper as your original signature is required on this form.
   • Alternatively, you can consolidate your super securely online by logging into your Members Online account at esssuper.com.au/login
   • To transfer your insurance cover to the ESSSuper Accumulation Plan, complete the Insurance and Super Transfer Form (ES174) available at
      esssuper.com.au/forms.
   Please complete this form in pen using CAPITAL letters and mark with an [ ] where applicable.

    Section 1                       Your personal details

   Member number                                                                     (leave blank if you are a new ESSSuper member)

   Title                               Mr             Mrs              Ms            Miss           Other (please specify)

   Surname

   Given names

   Date of birth                             /               /

   Postal address

                                  Suburb

                                  State                      Postcode

                                       Mark with an [ ] if your postal and residential address are the same. If your residential address is different, please specify below.

   Residential address

                                  Suburb

                                  State                      Postcode

   Telephone (business hours) (                   )                                             (after hours) (                 )

   Telephone (mobile)

   Email address
           By providing your email address, you are authorising ESSSuper to send communications including statement notifications to that address. This authorisation
           will apply until it is revoked by you. I understand I can change my communication preferences at any time by calling ESSSuper on 1300 650 161 (for emergency
           services members) or 1300 655 476 (for state super members) or through the My details/Manage preferences section of MembersOnline.

                                                                                          You are not obliged by law to provide your TFN but there may be adverse
   Tax File Number                                -                    -                  tax consequences if you don’t (refer to the relevant PDS or contact us for
                                                                                          more information).

   OFFICE USE ONLY                INS FORM ATT                   Yes            No

Issued by: Emergency Services Superannuation Board ABN 28 161 296 741 as Trustee of the Emergency Services Superannuation Scheme ABN 85 894 637 037
                                                                                                                                                             July 2021 1 of 3
Transfer your super                                                                                                       ES104

   Section 2                How many super funds are you transferring money from?

  How many super funds
  are you transferring
  money from?

   Section 3                Details of super funds you are transferring money from

  Fund 1                   Please provide the details of the super fund that you are transferring from:

  Member number

  Name of super fund
  Postal address of
  super fund
                           Suburb

                           State                  Postcode

  Telephone                 (            )

  Fund ABN                           -            -                    -
                                                Postal address of
  I want to rollover:           My whole benefit super fund

                                Only part of my benefit. Please provide the amount.       $     ,          ,   .

  Fund 2                   Please provide the details of the super fund that you are transferring from:

  Member number

  Name of fund

  Postal address of fund

                           Suburb

                           State                  Postcode

  Telephone                 (            )

  Fund ABN                           -                -                -

  I want to rollover:           My whole benefit

                                Only part of my benefit. Please provide the amount.       $     ,          ,   .

  Fund 3                   Please provide the details of the super fund that you are transferring from:

  Member number

  Name of fund

  Postal address of fund

                           Suburb

                           State                  Postcode

  Telephone                 (            )

  Fund ABN                           -                -                -

  I want to rollover:           My whole benefit

                                Only part of my benefit. Please provide the amount.       $     ,          ,   .

                                                                                                                  July 2021 2 of 3
Transfer your super                                                                                                                                         ES104

   Section 4                     Details of ESSSuper product you are transferring to

  Name of fund                  E    S    S    S    U    P    E   R

  ABN                           8    5    -    8    9    4    -    6   3    7    -    0    3    7

  Product you are                   Accumulation Plan (USI: ESS0003AU)
  rolling over to:
                                    Income Stream (USI: ESS0002AU)

                                    Beneficiary Account (USI: ESS0001AU)

   Section 5                     Declaration and signature

                               I authorise the rollover of the superannuation benefits I have listed on this form to ESSSuper, and in doing so:
                               • I acknowledge that I have read the relevant Product Disclosure Statement available from ESSSuper.
                               • I acknowledge and accept that the benefits in the Accumulation Plan, Income Streams and Beneficiary
                                 Account (including Spouse Accounts) are not guaranteed or underwritten by the Victorian Government or
                                 the Emergency Services Superannuation Board and that ESSSuper does not come under the jurisdiction of
                                 the Australian Financial Complaints Authority.
                               • I understand and acknowledge the implications and effects of transferring my benefits from my
                                 superannuation fund/s to ESSSuper.
                               • I discharge the superannuation provider of my transferring super fund/s of all further liability in respect of my
                                 superannuation benefit paid and transferred to ESSSuper.
                               • I understand that ESSSuper is required to deduct tax from any untaxed portion of my transfer.
                               • I authorise ESSSuper to make any necessary enquiries of the transferring super fund/s to give effect
                                 to the transfer.
                               • I am aware I may ask my superannuation provider for information about any fees or charges that may apply,
                                 or any other information about the effect this transfer may have on my benefits such as insurance cover,
                                 and do not require any further information.
                               • I have read and accept the statements relating to privacy in the relevant Product Disclosure Statement and
                                 I consent to providing ESSSuper with my personal information pursuant to the Privacy and Data Protection
                                 Act 2014 for the purposes described in ESSSuper ’s Privacy Policy and Privacy Collection Statement available from
                                 our website at esssuper.com.au

  Signature of                   PLEASE SIGN HERE                                                        Date               /              /
  account holder

  Please post the completed form with your original signature to
  ESSSuper GPO Box 1974, Melbourne Vic 3001
  T 1300 650 161 | W 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 copies of ESSSuper’s Privacy Policy and Privacy
  Collection Statement, please visit our website at esssuper.com.au

                                                                                                                                                    July 2021 3 of 3
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ES151

Regular contributions
Issued: 1 July 2021

           IMPORTANT — ONCE COMPLETED PLEASE FORWARD THIS FORM TO YOUR PAYROLL OFFICE OR HR SECTION.

    Who should use this form?

   You should complete this form if you want to commence making personal (after-tax) or salary sacrifice (before-tax) contributions to the
   ESSSuper Accumulation Plan by regular payroll deduction through your employer.
   However, if you want to salary sacrifice and you are employed by the Department of Education & Training as a school-based staff member
   or principal, you need to complete the Salary Sacrifice for DE&T members to an Accumulation Plan (via SmartSalary.com.au) form instead,
   which is available from the ESSSuper website at esssuper.com.au/forms or by calling the ESSSuper Member Service Centre on
   1300 655 476. Please return that form to SmartSalary.

    Important information for employers

   Employers who are not a Victorian Public Sector participating employer, or who have not at any time made contributions to ESSSuper on
   behalf of an employee, can register with ESSSuper before remitting contributions by logging into EmployerDirect.

    Before you start

   This form acts as an authorisation for your employer to deduct an amount from your pay and to pay this amount as a superannuation
   contribution to ESSSuper’s Accumulation Plan. Your employer may also require you to complete their own form.
   If you already have an Accumulation Plan account, your contributions will be invested in accordance with your most recent investment
   choice for contributions into your Accumulation Plan account. You can change your investment choice for future contributions at any time.
   If you do not currently have an account in ESSSuper’s Accumulation Plan, you will need to complete the Accumulation Plan application
   form (E166) online by logging into your Members Online account at esssuper.com.au/login. Alternatively you can complete the form that
   accompanies the Accumulation Plan Product Disclosure Statement and forward your completed form to ESSSuper.
   To find out when these deductions will commence and when contributions will be forwarded to ESSSuper, please contact your employer.
   ESSSuper is not responsible for ensuring deductions are made and forwarded to ESSSuper by your employer.

   Please complete this form in pen using CAPITAL letters and mark with an [ ] where applicable.

    Section 1                   Your personal details

   Employee/Payroll no.

   Title                           Mr            Mrs          Ms            Miss         Other (please specify)

   Surname

   Given names

   Date of birth                         /             /

   Telephone (business hours) (              )                                       (after hours) (              )

   Telephone (mobile)

Issued by: Emergency Services Superannuation Board ABN 28 161 296 741 as Trustee of the Emergency Services Superannuation Scheme ABN 85 894 637 037
                                                                                                                                           July 2021 1 of 2
Regular contributions                                                                                                                                       ES151

   Section 2                     Your contribution instructions

                               There are Government imposed limits on the amount of contributions that can be made by a person in a
                               financial year without additional tax applying. For more information, refer to the How super is taxed guide (AP.4).

  Please deduct                   $      ,             .
                               from my pay each pay period and pay this amount on my behalf as a superannuation contribution
                               to ESSSuper ’s Accumulation Plan.

  Please deduct                       After tax
  this amount
                               OR

                                      Before tax (salary sacrifice)

   Section 3                     Declaration and signature

                               • I have read the Accumulation Plan Product Disclosure Statement and Incorporated Guides available
                                 from ESSSuper.
                               • I understand that if I do not provide my tax file number to ESSSuper, it cannot accept after-tax contributions
                                 made by me and any salary sacrifice contributions I make will be taxed at the top marginal rate of 47%
                                 (including Medicare levy of 2%).
                               • I understand that the amount I have nominated on this form will be deducted from my pay each pay
                                 period by my employer and will be forwarded to ESSSuper as a superannuation contribution to the
                                 Accumulation Plan.
                               • I understand that the amount I have nominated on this form will continue to be deducted by
                                 my employer until the earlier of the date I provide my employer with a new instruction or the date
                                 I terminate employment.
                               • I accept ESSSuper is not responsible for ensuring that deductions are made and forwarded to ESSSuper
                                 by my employer.
                               • I understand that contributions must be preserved in the superannuation system until I become
                                 eligible to access my superannuation benefit.
                               • I accept that the benefits in ESSSuper ’s Accumulation Plan are not guaranteed or underwritten by the
                                 Victorian Government or Emergency Services Superannuation Board and do not come under the
                                 jurisdiction of the Australian Financial Complaints Authority.

  Signature of                   PLEASE SIGN HERE                                                        Date               /              /
  account holder

          IMPORTANT — ONCE COMPLETED PLEASE FORWARD THIS FORM TO YOUR PAYROLL OFFICE OR HR SECTION.

  Please forward the completed form to your payroll office or HR Section.
  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 copies of ESSSuper’s Privacy Policy and Privacy
  Collection Statement, please visit our website at esssuper.com.au

                                                                                                                                                    July 2021 2 of 2
ES142

Choice of superannuation fund
For super contribution payments from your employer
(Accumulation Plan only)
Issued: 1 July 2021

    How to use this form
   If you’d like your employer to pay your future Superannuation Guarantee and/or salary sacrifice contributions into your ESSSuper
   Accumulation Plan account, please complete your details below and GIVE THIS FORM TO YOUR EMPLOYER. Do not send this
   completed form to ESSSuper or the Australian Taxation Office (ATO).
   If you’re not a current member of the ESSSuper Accumulation Plan, please contact us via esssuper.com.au/contact-us

    Section 1                   Your personal details

   Member number                                                                           Date of birth              /             /

   Given names

   Surname
   Declaration                I request that all future employer contributions are to be made to my ESSSuper Accumulation Plan account.
                              I consent to my information being collected, disclosed, and used by my employer for the purposes of
                              contributing to my superannuation account in the manner set out in this form.

   Signature                    PLEASE SIGN HERE                                                   Date              /             /

    Section 2                   For your employer

   Scheme                     Emergency Services Superannuation Scheme             How to contribute to ESSSuper
   Status                     Complying Fund                                       You don’t need to register with ESSSuper to make
   Basis                      Exempt Public Sector Superannuation Scheme           contributions via SuperStream. We do not accept
                                                                                   contribution payments through EFT, cheque, or BPAY.
   SFN                        26 91 249 42
                                                                                   For more information about making contributions,
   Fund ABN                   85 894 637 037
                                                                                   contact us or refer to esssuper.com.au/employers
   USI                        ESS0003AU
   Postal address             GPO Box 1974, Melbourne VIC 3001
   Phone number               1300 650 161 (Emergency services members) or 1300 655 476 (State super members)
   Website                    esssuper.com.au

   Statement of               In accordance with section 10 (1) of the Superannuation Industry (Supervision) Act 1993 (SIS Act) (definition
   compliance                 of exempt public sector superannuation scheme refers) and as listed in Schedule 1AA of the Superannuation
                              Industry (Supervision) Regulations 1994, the Emergency Services Superannuation Scheme (trading as ESSSuper –
                              Emergency Services & State Super) is declared an “Exempt Public Sector Superannuation Scheme”.
                              Subsequently, under section 45 (6) of the SIS Act, the Scheme is deemed to be a complying superannuation fund
                              for tax purposes.
                              ESSSuper is eligible to receive Superannuation Guarantee contributions from employers.

      T 1300 650 161 (Emergency services members) or 1300 655 476 (State super members) | E info@esssuper.com.au | W esssuper.com.au

Issued by: Emergency Services Superannuation Board ABN 28 161 296 741 as Trustee of the Emergency Services Superannuation Scheme ABN 85 894 637 037
                                                                                                                                           July 2021 1 of 1
Proudly
serving our
members
Level 16, 140 William Street
Melbourne VIC 3000
GPO Box 1974
Melbourne VIC 3001
T 1300 650 161
E info@esssuper.com.au
W esssuper.com.au
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