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  • How do you complete this form?

    Section A: Your fund’s details

    Complete all the details of the super fund you are paying your contributions to.

    Section B: Your details

    Provide your personal details to your super fund.

    We do not collect the personal details you provide on this form. This form is to assist you in providing details to your super fund. Your super fund is authorised to request your personal details, including your TFN, under the Superannuation Industry (Supervision) Act 1993.

    It is not an offence if you do not provide your TFN. However, if you do not provide your TFN and your super fund does not already hold your TFN, they cannot accept the contribution covered by this form. For more information about your privacy please contact the super fund you are providing this form to.

    Section C: Legal representative’s details

    If your legal representative completes this form on your behalf, they must provide their details.

    Your super fund may need your authorisation to deal with your legal personal representative.

    Section D: Amount

    Provide the amount from your personal injury payment that you wish to exclude from your non-concessional contributions cap.

    Section E: Declaration

    Read the declaration thoroughly. If it is correct, print your full name, sign and date the declaration. The date is important and must be the actual date you sign the form. If you make a false declaration, you may be penalised. If the form is completed by your legal representative, they will need to sign the declaration on your behalf.

    Give your signed and dated form to your super fund before or when you make the contribution. If you lodge it late – after making your contribution – it won’t be valid and your super fund will have to reject it.

    Do not send this form to us. It’s only valid if you give it to your super fund. Your super fund will report to us that you have notified them of your structured settlement when it reports all your contributions for the year.

    More information

    See also:

    Last modified: 08 Sep 2017QC 19583