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  • How to complete the form

    You must:

    • write each letter in a separate box
    • use a black pen
    • use BLOCK LETTERS.

    You do not have to complete every field. For example, where an amount has not been paid or withheld, leave those boxes blank.

    Show all amounts in whole dollars, do not show cents. For example, show an amount of $122.76 as $122.

    Payment summary for year ending 30 June

    The year must be shown as a four-digit figure. For example, the year ending 30 June 2017 must be shown as 2017 and not 17.

    Section A: Payee details

    If the payment is a superannuation lump sum death benefit, the payee is one of the following:

    • trustee for the deceased employee's estate
    • non-dependant of the deceased person
    • dependant of the deceased person.

    Tax file number

    You must show the tax file number (TFN) the payee quoted.

    For example, show a nine-character TFN as:

    Example of the completed 'Tax file number' field of the form.

    To help us process your form, you must substitute the TFN with one of the numbers listed below if:

    • a new payee has not made a TFN declaration, but 28 days have not passed – use code 111 111 111.

    the payee is under 18 and earnings do not exceed $350 per week, $700 per fortnight or $1,517 per month – use 333 333 333.

    • the payee is an Australian Government pensioner – use 444 444 444.
    • the payee chose not to quote a TFN and has not claimed an exemption from quoting a TFN or does not fit into any of these categories – use 000 000 000.


    Separate the surname or family name from the given name/s and print in the boxes.

    For example, show Jane Mary Covers as:

    Example of the completed 'Name' fields of the form.

    Residential address

    You must show the street number and name, suburb/town/locality, state or territory, and postcode, separately in the boxes provided.

    For example, show the address:2 Bell St Ablem  WA  6999 as:

    Example of the completed 'Residential address' fields of the form.

    Date of birth (if known)

    Provide this information if you have it. Leave blank if the payment is a super lump sum death benefit.

    Use the format DDMMYYYY, for example:

    Example of the completed 'Date of birth' field of the form.

    Last modified: 29 Apr 2021QC 35966