MO016.

1405 (formerly 8106)

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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 for mortgage assistance. You may be eligible if:
the property under threat of sale is your usual place of
residence and you are responsible for the mortgage
repayments, and
the mortgagee is threatening to repossess or sell your home
due to arrears on your mortgage, and
you lack the financial capacity to pay the arrears without
accessing your superannuation.
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 nal decision to release your superannuation early, rests with
the trustee of your superannuation fund(s). You must contact your
superannuation fund(s) to conrm they will release your
superannuation if this application is approved.
Proof of identity
You must prove your identity by providing 100 points of certied
identication. All documents supplied need to be clearly certied
copies. Do not send originals. Each identication 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 identication and their point value go to our website
www.humanservices.gov.au/earlysuper
Documentation from mortgage provider
You need to provide a letter or legal notice from your mortgagee
which states (separately for each loan you have secured by your
home):
if the arrears amount is not paid within a specified timeframe,
they will foreclose the mortgage or take possession of or sell
the security property, and
the current amount owing that must be paid in order to cease
action to sell your property, and
the address of the property under threat of sale, and
the amount equal to 3 months repayments on the loan(s), and
the amount equal to 12 months interest on the outstanding
balance of the loan(s), and
the mortgagees name and the loan account number.
Letter(s) from your mortgage provider need to be on letterhead and
dated no older than 30 days from the date of this application.
For an information guide to assist mortgage providers go to our
website www.humanservices.gov.au/earlysuper
Depending on your circumstances we may need to request
additional information to make a decision on your application.
Release amount
The cashing restrictions in Schedule 1, Part 1, Item 107 of the
Superannuation Industry (Supervision) Regulations 1994 and
Schedule 2, Part 7, Item 109 of the Retirement Savings Accounts
Regulations 1997 state that in each 12 month period, the amount
that can be released does not exceed the sum of:
3 months repayments, and
12 months interest on the outstanding balance of the loan.
The assessment of the amount to be released is based on the
amount needed to prevent the forced sale of your principal place of
residence.
Early Release of Superannuation on
Specified Compassionate Grounds
Mortgage Assistance
MO016.1405 (formerly 8106)
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Superannuation fund details
Important: Make sure that accessing your superannuation is the
right nancial option for you. The amount of superannuation you
receive may be included in your taxable income, which can impact
your nancial situation. We recommend that you get independent
nancial 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 Ofce.
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 funds 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

1000377
Exact fund balance as of todays 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 arrears.
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
www.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.
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Early Release of Superannuation on
Specified Compassionate Grounds
Mortgage Assistance
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: [email protected]
Applicants details
1 Dr Mr Mrs Miss Ms Other
Family name
First given name
Other given name(s)
Previous name(s) (if applicable)
2 Date of birth
/ /
3 Your sex
Male
Female
4 Address
Postcode
5 Postal address (if different to above)
Postcode
6 Home phone number
( )
Work phone number
( )
Mobile phone number
Email
@
7 What 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
Ofce for further information.
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Superannuation fund(s)
Contact your superannuation fund to obtain your superannuation
account(s) current balance.
8 Superannuation fund 1
Full superannuation fund name
Member number
Fund ABN
Registrable Superannuation Entity (RSE) number.
This number is available on your funds 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 todays 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 funds 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 todays 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
9 Are you employed?
Employment can mean full time, part time or casual work for
which you are paid
No Go to 12
Yes
10 On what basis are you employed?
Permanent full or part time
Temporary
Casual
Other Give details
11 What is your income from employment after tax?
$
Weekly
Fortnightly
Monthly
12 Are you receiving a Commonwealth Income Support Payment
(e.g. Centrelink benets)?
No Go to 14
Yes
13 What is your income from Support Payments?
$
Weekly
Fortnightly
Monthly
14 Do you receive income from any other source?
No Go to 17
Yes
15 Where do you receive the income from (e.g. from investment
properties or shares)?
16 How much do you receive?
$
Weekly
Fortnightly
Monthly
17 Do you have a partner?
No Go to 27
Yes
18 Your partners full name
19 Is your partner employed?
Employment can mean full time, part time or casual work for
which your partner is paid.
No Go to 22
Yes
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20 On what basis is your partner employed?
Permanent full or part time
Temporary
Casual
Other Give details
21 What is your partners income from employment after tax?
$
Weekly
Fortnightly
Monthly
22 Is your partner receiving a Commonwealth Income Support
Payment (e.g. Centrelink benets)?
No Go to 24
Yes
23 What is your partners income from Support Payments?
$
Weekly
Fortnightly
Monthly
24 Does your partner receive income from any other source?
No Go to 27
Yes
25 Where does your partner receive the income from (e.g. from
investment properties or shares)?
26 How much does your partner receive?
$
Weekly
Fortnightly
Monthly
27 Do any other members of your household contribute towards
household costs?
No Go to 30
Yes
28 How much do they contribute?
$
Weekly
Fortnightly
Monthly
29 Relationship to you
Assets
30 Do 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?

$
31 Do you hold shares or other investments?
No
Yes What is their value?

$
32 What is the estimated value of your household goods?
$
33 Have you received funding from the National Disability
Insurance Scheme?
No
Yes Give details
Funding received
$
Current balance
$
34 Please 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)?
$
35 What 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)?
$
36 Do you and/or your partner own a motor vehicle(s)?
No Go to 39
Yes
37 How many vehicles do you and/or your partner own?
38 Total estimated value of vehicle(s)
$
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39 Estimate 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
40 Do you and/or your partner have any loans with nancial
institutions or outstanding debts (e.g. debts to Centrelink, the
Australian Taxation Ofce, loans from family etc)?
No Go to 44
Yes
41 How many loans/debts do you and/or your partner have?
42 What 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 Ofce debt
Loan from third party
Other Give details
43 What is the total monthly loan/debt repayment amount for your
and/or your partners loan(s)?
$
44 Do you and/or your partner have any credit cards including store
cards?
No Go to 49
Yes
45 How many credit cards do you and/or your partner have?
46 What is the total balance owing on your and/or your partners
credit card(s)?
$
47 What is the total credit limit of your and/or your partners credit
card(s)?
$
48 What is the total monthly credit card repayment amount for
your and/or your partners credit card(s)?
$
49 Are you currently registered as bankrupt?
No
Yes
Attach a letter from your trustee which
conrms that a release of your
superannuation will be exempt from
assessment under your bankruptcy
agreement.
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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
50 What are your monthly household expenses?
Please complete all elds. 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
51 Do 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
52 Is another person applying with you for the early release of
superannuation to pay for the same expenses?
No Go to 56
Yes
53 Other applicants full name
54 Can we contact the other applicant to discuss your application?
No
Yes
This information will assist in processing your application and
reduce any unnecessary delays.
55 Do we have permission to speak with the other applicant if they
call us?
No
Yes
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Mortgage
56 Are you applying to pay arrears on a mortgage to prevent the
sale of your home?
No Go to 62
Yes
57 Have you received a written notice from a mortgagee that states
they intend to sell or take possession of your home or foreclose
if the arrears amount is not paid by a certain date?
No
Yes
58 What is the address of the property under threat?
Postcode
59 Are you listed as a borrower on the mortgage for the property
under threat of sale?
No
Yes Go to 62
60 Who is listed as the borrower on the mortgage?
61 What is your relationship to the borrower(s)?
62 Other than the mortgagee, is there any other third party
threatening to sell your home?
No
Yes What is the name of the third party?
Attach a separate sheet with details of the
arrangement under which the party has the
legal right to sell your property.
Property details
63 Do you currently live in the property under threat of sale?
No Why do you live elsewhere?
Yes Go to 69
64 What is the address of the property where you are currently
living?
Postcode
65 How long have you been living at this address?
Month(s) Year(s)

66 Do you own this property?
No
Yes
67 Does your family live with you?
No What is the address of the property where your family
is currently living?
Postcode
Yes
68 What is the address of your permanent job?
Postcode
69 Is the property under threat currently listed for sale?
No
Yes
If additional properties need to be listed, attach a
separate sheet with details.
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Additional information
70 Did you tick No to both questions 56 and 62?
No
Yes If you ticked No to both questions 56 and 62 your
application could be declined.
71 Provide any additional information relevant to your application
If you need to provide more information, attach a
separate sheet with details.
Permissions
72 Do you want another person(s) or organisation(s) to enquire or
act on your behalf when dealing with us?
No Go to 74
Yes
73 Name 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 certied copy.
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Checklist
If you do not provide us with the relevant supporting documents,
your application may be declined.
74 Indicate which supporting documents you are attaching with
your application
100 points of certied identication
(refer to Proof of identity page 1)
Letter(s) from mortgage provider
(refer to Documentation from mortgage provider page 1)
Superannuation fund details
(make sure you have completed question 8)
A Power of Attorney if appropriate (refer to question 73)
Additional information that may have been
requested in the application
Privacy notice
75 Your 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
www.humanservices.gov.au/privacy or by requesting a copy from
the department.
Declaration
76 I 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 73 to act or enquire on my behalf.
Applicants signature
-
Date
/ /
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