Form

Certification of Immigration Status and/or

request to cancel a Temporary Resident visa 1194

About this form Request for cancellation of a Temporary Resident visa

Important – Please read this information carefully before you In order to claim a DASP either online with the ATO or by paper
complete this form. with your superannuation fund, you may need to formally
This form can be used to request a Certification of Immigration request the Department of Immigration and Citizenship (the
Status and/or to request the cancellation of a Temporary department) to cancel your Temporary Resident visa. The visa
Resident visa for the purposes of making a Departing Australia cancellation can be requested if you are outside Australia and
Superannuation Payment (DASP) claim with the Australian Tax you do not intend to return to Australia.
Office (ATO). By completing this form you can formally request the
department to cancel your visa, and those of your family
Important information about claiming DASP members or any other person who holds a visa because you
hold a visa.
The Departing Australia Superannuation Payment scheme is
administered by the Australian Taxation Office and the eligibility Please complete Parts A, C and D of this form if you are
requirements are set out in the Superannuation Industry requesting the department to cancel a Temporary Resident visa.
(Supervision) Regulations 1994. There is no fee associated with request for cancellation of a
If you accumulated superannuation while in Australia as a holder Temporary Resident visa.
of a Temporary Resident visa, you are eligible to claim DASP if
you meet all of the following requirements: Request for Certification of Immigration Status
• you have left Australia; If you intend to lodge a paper application for your DASP claim
• you were an eligible temporary resident; with your superannuation fund and your superannuation
• your Temporary Resident visa has ceased to be in effect withdrawal benefit is AUD5,000 or more, your superannuation
(ie. all Temporary Resident visas have expired or been fund requires you to provide a Certification of Immigration
cancelled); Status from the department as evidence that your Temporary
• you are not an Australian citizen, New Zealand citizen or Resident visa has ceased to be in effect and that you have left
Australian permanent resident. Australia.
If you are an Australian Citizen, an Australian Permanent Each person who wishes to request a Certification of
Resident, a New Zealand Citizen or for some other reason have Immigration Status must complete a separate form.
an option of retiring in Australia and have access to the age There is a fee associated with the request for Certification of
pension, then you will generally not be eligible for payment of Immigration Status (see Charges).
your superannuation benefits until you have reached retirement For paper lodged DASP applications where your superannuation
age. withdrawal benefit is less than AUD5,000 you can provide your
Applications for DASP claims can either be lodged: own evidence to your superannuation fund confirming that
• online with the ATO; or your Temporary Resident visa is no longer in effect
• paper application submitted to your superannuation fund. (ceased/cancelled) and that you have left Australia. This
evidence would generally include either a copy of your visa
DASP online is a free service provided by the ATO and includes grant notification letter or a copy of your visa label or visa
online verification of your immigration status to confirm that cancellation advice from the department as well as a copy of
your Temporary Resident visa has ceased to be in effect and your passport showing that you have left Australia.
that you have left Australia.
Note: If you are using the free ATO online DASP service, your
If you choose to claim DASP using the ATO paper application eligibility is verified online, confirming that your Temporary
form which is to be lodged directly with your superannuation Resident visa has ceased to be in effect and that you have left
fund, you will be required to provide evidence in support of Australia.
that application to confirm that your Temporary Resident visa
is no longer in effect and that you have left Australia.
Where to send this form
Further information about eligibility and the ATO DASP online
and paper application processes including the ATO DASP You can send the completed form to the department by:
application form is available from the ATO website • e-mail to [email protected]
www.ato.gov.au/departaustralia • post to:
or by writing to: Department of Immigration and Citizenship
Superannuation Certification and Cancellation Team
Australian Taxation Office GPO Box 1496
PO Box 3100 HOBART TAS 7001
PENRITH NSW 2740
• fax to: +61 3 6281 9453
AUSTRALIA
Note: ATO DASP claim forms sent to the department will be
returned to the sender.

© COMMONWEALTH OF AUSTRALIA, 2013 1194 (Design date 07/13) - Page 1

 What happens after you have lodged this form? Integrity of the information you provide
For visa cancellations – when the request is finalised the The department is committed to maintaining the integrity of
department will send you a letter either by e-mail or post. the visa and citizenship programs. Please be aware that if you
For Certification of Immigration Status requests – when the provide us with fraudulent documents or claims, this may result
request is finalised the department will e-mail the Certification in processing delays and possibly your request being denied.
of Immigration Status directly to your nominated
superannuation fund(s) and will send a copy to you either by Consent to communicate electronically
e-mail or post. The department may use a range of means to communicate
Note: The department allows 21 days for a letter sent by post with you. However, electronic means such as fax or e-mail will
to be received at an overseas address. only be used if you indicate your agreement to receiving
communication in this way.
Charges To process your application the department may need to
There is a fee associated with the request for Certification of communicate with you about sensitive information, for example,
Immigration Status but there is no fee associated with the health, police checks, financial viability and personal
request to cancel your Temporary Resident visa. relationships. Electronic communications, unless adequately
encrypted, are not secure and may be viewed by others or
Payment must accompany your request for Certification of interfered with. If you agree to the department communicating
Immigration Status and is not generally refunded if your request with you by electronic means, the details you provide will only
is not successful. be used by the department for the purpose for which you have
Fees may be subject to adjustment at any time, with many provided them, unless there is a legal obligation or necessity to
charges subject to adjustment on 1 July each year. This may use them for another purpose, or you have consented to their
increase the cost of making a request for Certification of use for another purpose. They will not be added to any mailing
Immigration Status. list without your consent.
To check the application charge, refer to the department’s The Australian Government accepts no responsibility for the
website www.immi.gov.au/fees-charges or check with the security or integrity of any information sent to the department
nearest office of the department. over the internet or by other electronic means.

Method of payment About the information you give

The storage, use and disclosure by the department of the
In Australia
information you provide in this form is governed by the Privacy
To make a payment, please pay by credit card, debit card, bank Act 1988. If you want more information about this, you should
cheque or money order (made payable in Australian dollars) to see the information form 993i Safeguarding your personal
the Department of Immigration and Citizenship. Debit card and information, available from www.immi.gov.au/allforms/ or
credit card are the preferred methods of payment. the nearest office of the department.
Outside Australia
Before making a payment outside Australia, please check with
the Australian Government office where you intend to make
the payment as to what methods of payment and currencies
they can accept and to whom the payment should be made
payable. Home page www.immi.gov.au
Send this form, together with the receipt of payment, to: General Telephone 131 881 during business hours
Department of Immigration and Citizenship enquiry line in Australia to speak to an operator (recorded
Superannuation Certification and Cancellation Team information available outside these hours).
GPO Box 1496 If you are outside Australia, please contact
HOBART TAS 7001
your nearest Australian mission.
AUSTRALIA

Please keep these information pages for your reference

1194 (Design date 07/13) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2013
 Form
Certification of Immigration Status and/or
request to cancel a Temporary Resident visa 1194

Please use a pen, and write neatly in English using BLOCK LETTERS. 4 Sex Male Female
Tick where applicable 
DAY MONTH YEAR

Part A – Your details 5 Date of birth

Part A must be completed by:

6 Country of birth
• the person requesting a Certification of Immigration Status (each
person requesting certification must complete a separate form); or
• for visa cancellation only, the main visa holder. 7 Country of
citizenship
1 Your full name 8 Have you departed Australia?
Family name No

Given names Yes

2 Your name as shown in your travel document on entry to Australia on 9 Current address for correspondence
the Temporary Resident visa
(If the same as your present name, write ‘AS ABOVE’)

Family name POSTCODE

Given names
10 Telephone numbers
Reason for change: COUNTRY CODE AREA CODE NUMBER

Deed poll Office hours ( ) ( )

Marriage After hours ( ) ( )

Other
11 Do you agree to the department communicating with you by fax, e-mail
Evidence of any name changes must be provided, eg. marriage certificate, or other electronic means?
deed poll evidence, etc. (All documents MUST be certified copies)
No
3 Have you been known by any other names? Yes Give details
(including name at birth, previous married names, aliases) COUNTRY CODE AREA CODE NUMBER

No Fax number ( ) ( )

Yes Give details E-mail address

Family name

Given names 12 Are you using this form to request Certification of Immigration Status?
No Go to Part C
Reason for change:
Yes Go to Part B
Deed poll
Marriage

Other

If you have been known by any names other than these names, please
provide documentary evidence. (All documents MUST be certified copies)

© COMMONWEALTH OF AUSTRALIA, 2013 1194 (Design date 07/13) - Page 3

 Part B – Request Certification of 2. Fund name
Immigration Status
13 Details of entry to Australia on the Temporary Resident visa Fund address
DAY MONTH YEAR

Date of first arrival

Place of arrival POSTCODE

Flight number/ Fund e-mail address

name of ship (if known)
Passport number when
you arrived in Australia
If there are more than 2 funds, attach a separate sheet.

14 Details of departure from Australia

DAY MONTH YEAR 17 Payment details
Date of last departure How will you pay the charge?
If applying in Australia, debit card or credit card are the preferred
Place of departure methods of payment. Debit cards cannot be used for requests lodged by
Flight number/ mail. If paying by bank cheque or money order please make payable to
name of ship (if known) the Department of Immigration and Citizenship in Australian dollars.
Passport number when If applying outside Australia, please check with the Australian
you departed Australia Government office where you intend to make the payment as to what
methods of payment and currencies they can accept and to whom the
15 If you arrived as a child (under 18) and no longer hold the payment should be made payable.
passport or travel document you used on your first arrival,
please give the following details Bank cheque Please make payable to:
Parent’s full name Money order Department of Immigration and Citizenship

Debit card Cannot be used for applications lodged by mail

Parent’s former name
(if applicable) Credit card Give details below
DAY MONTH YEAR

Parent’s date of birth Payment by (tick one box) Australian Dollars

Sex Male Female MasterCard Diners Club

American Express JCB AUD
Parent’s full name Visa

Parent’s former name Credit card number

(if applicable) : : : : : : : : : : : : : : : : : :
DAY MONTH YEAR
MONTH YEAR
Parent’s date of birth
Expiry date : :
Sex Male Female
Cardholder’s name

16 Provide details of your superannuation fund(s)

(Fund details must be provided because Certifications of Immigration COUNTRY CODE AREA CODE NUMBER

Status will be sent electronically to individual funds) Telephone ( ) ( )

number
1. Fund name Address

POSTCODE
Fund address

Signature of
cardholder
POSTCODE
Credit card information will be used for charge paying purposes only.
Fund e-mail address
18 Are you also using this form to request cancellation of a Temporary
Resident visa?
No Go to Part D
Yes Go to Part C

1194 (Design date 07/13) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2013

Part C – Request cancellation of a 19 Your passport number when you arrived in Australia on the Temporary
Temporary Resident visa Resident visa

Only complete Part C if you still hold a Temporary Resident visa that can
be used to travel to and enter Australia.
20 Details of the visa you currently hold
If you currently hold a valid visa for travel to Australia you will not be
eligible for refund of your superannuation funds until that visa expires or Subclass
is cancelled. You may request to have your eligible Temporary Resident
visa cancelled by completing this Part. Name of visa
subclass
Cancellation procedures Visa grant number
(if known)
You should note that:
• a request for visa cancellation made on this form will only be DAY MONTH YEAR
considered in respect of eligible Temporary Resident visas; 21 Date of departure from Australia
• requesting cancellation of a current eligible Temporary Resident visa
is entirely optional; 22 Give details of all persons (excluding yourself) who hold a visa because
• visa cancellation decisions will be made under Section 128 of the they are a member of your family unit, or hold a visa only because you
Migration Act 1958; hold your visa. (This includes, but is not limited to, persons who were
• visa cancellation under Section 128 of the Migration Act 1958 is included in your visa application.)
discretionary;
1. Family name
• visa cancellation can only be considered under Section 128 of the
Migration Act 1958 where the visa holder is outside Australia; Given names
• if your visa is cancelled, the Migration Act 1958 requires that you be DAY MONTH YEAR
sent a notice stating the grounds for cancellation; Date of birth
• there is no fee payable for visa cancellation.
Passport number when they arrived in Australia on
Consequences of your visa cancellation for other persons the Temporary Resident visa
If your visa is cancelled:
• any visa(s) held by members of your family unit, that are held only
because you hold your visa, will also be cancelled whether they are Subclass of visa
currently held
inside or outside Australia;
• any visa(s) held by persons, other than members of your family unit, Name of visa subclass currently held
that are held only because you hold your visa, may also be cancelled
whether they are inside or outside Australia;
Visa grant number (if known)
• if a person’s visa is cancelled while that person is inside Australia,
that person will become an unlawful non-citizen and liable to
immigration detention and there will be restrictions on any further Date of departure DAY MONTH YEAR

visa application they can make while they are in Australia. from Australia
Future travel to Australia
If your visa is cancelled: 2. Family name
• no further travel to Australia will be permitted until such time as a Given names
further visa has been granted;
DAY MONTH YEAR
• any future visa application you make will be considered on its merits
Date of birth
at the time of application;
• the cancellation of your visa while you are outside Australia will not Passport number when they arrived in Australia on
prevent you making any future visa applications outside Australia. the Temporary Resident visa

Subclass of visa
currently held
Name of visa subclass currently held

Visa grant number (if known)

DAY MONTH YEAR

Date of departure
from Australia

If there are more than 2 people, attach a separate sheet.

© COMMONWEALTH OF AUSTRALIA, 2013 1194 (Design date 07/13) - Page 5

 Part D – All applicants to complete Declaration
Assistance with this form WARNING: Giving false or misleading information is a serious offence.
28 • I declare that the information I have supplied in this form is
23 Did you receive assistance in completing this form? complete, truthful and correct in every detail.
No Go to Question 27 If applying for Certification of Immigration Status:
Yes Please give details of the person who assisted you • I consent to the Department of Immigration and Citizenship
sending a Certification of Immigration Status containing my
Title: Mr Mrs Miss Ms Other personal information, together with attachments (if any), to the
superannuation fund(s) nominated in this form.
Family name
If applying for cancellation of a visa:
Given names • I have read and understood the information provided in Part C
Address with respect to requesting visa cancellation, and
• I request the Minister for Immigration and Citizenship to cancel
my current eligible Temporary Resident visa.

POSTCODE
Your signature

Telephone number or daytime contact

DAY MONTH YEAR
COUNTRY CODE AREA CODE NUMBER

Office hours ( ) ( ) Date

Mobile/cell
We strongly advise that you keep a copy of this form and all
attachments for your records.
24 Is the person an agent registered with the Migration Agents Registration
Authority (MARA)?
No
Yes Go to Question 27

25 Is the person/agent in Australia?

No Go to Question 27
Yes

26 Did you pay the person/agent and/or give a gift for this assistance?
No
Yes

Options for receiving written

communications
27 All written communications about this application should be sent to:
(Tick one box only)
Myself

OR
Authorised You should complete form 956A Appointment
recipient Office use only
or withdrawal of an authorised recipient
OR Payment received
Migration agent Your migration agent/exempt person should
complete form 956 Advice by a migration Name of payer
OR agent/exempt person of providing Amount paid AUD
Exempt person immigration assistance
DAY MONTH YEAR

Date

Office

Comments

1194 (Design date 07/13) - Page 6 © COMMONWEALTH OF AUSTRALIA, 2013