Nomination of Beneficiary

A member shall nominate the person(s) (being" dependant" as defined in the rules governing the Fund) the member desires to receive benefits payable upon the death of the member, and may revoke the nomination at any time.

Member Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Payroll ID(Required)

I hereby nominate the following person(s) as beneficiary(ies) in respect of any benefit payable upon my death:

Beneficiary 1(Required)

First Last

Beneficiary 1 Relationship to Member(Required)

Beneficiary 1 Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

We highly recommend you add a Beneficiary 2 if your spouse is listed as Beneficiary 1. The full amount will go to the first nominated Beneficiary and then will carry forward to the 2nd and 3rd in accordance with your preference.

Beneficiary 2

First Last

Beneficiary 2 Relationship to Member

Beneficiary 2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Beneficiary 3

First Last

Beneficiary 3 Relationship to Member

Beneficiary 3 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signature

Date

Payroll Deduction Authority

to: Payroll - Team 10, Shared Services SA

Full Name(Required)

Payroll ID(Required)

I hereby authorise you to deduct from my Salary or Wages the sum of(Required)

$9 per fortnight

$12 per fortnight

OR such other amount from time to time payable to the Fire Service Fund. All such payments made on my behalf pursuant to this request shall be deemed as payments made by me.

Should the contributions payable by me in respect of the levy under which I am covered be varied by the Fire Service Fund in accordance with the Rules, I authorise you to accept and act upon written notification of such variation from the Fire Service Fund by deducting from my salary or wages (commencing on the date nominated) the new contribution payable by me.

THIS REQUEST CANCELS ANY EXISTING AUTHORITY.

Signature(Required)

Date(Required)

Witness(Required)

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