Budget and Payment Authority Form JAWS Compatible by pEKxTDd


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                                                                                                                               AccessPay logo

This is the form that we use to set up your salary packaging budget. You may have heard AccessPay refer to this as the yellow form. If
you need to contact us about this form you can contact us on telephone 1300 133 697, facsimile 1300 361 498, email
info@accesspay.com.au, postal address GPO Box 1238, Adelaide SA 5001. Upon completion of this form please print, sign and return
to AccessPay. Alternatively we will accept an unsigned email.
Title: Select your title by entering an X in the cell adjacent to the correct option
        Mr:                           Mrs:                          Ms:                        Miss:               Other:
    Surname:                                                                        Date of Birth:
 First Name:                                                              Your Phone Number:
   Employer:                                                                    Payroll Number:
Please complete the details in the rows below and ensure you attach the relevant supporting documentation for your bank
accounts and payments:
                                                Is the
                               Is the      expense to be
   Please provide a                                              Please          Please provide details of the
                            expense to         paid by                                                         What is the
  description of the                                            provide           account name and account
                              be paid        Electronic                                                        date for this Amount
       expense                                              details of the         number or BPay reference
                            fortnightly,       Funds                                                           payment to       $
 * Attach supporting                                          BSB/BPay         number – this is where we need
                             weekly or        Transfer,                                                        commence?
      documents                                              Biller Code              to send your money
                             monthly?         BPay or
 Example: Mortgage           Fortnightly         EFT            123456               123456789 Ms J Citizen       3/8/10     $617.29

I authorise the above payments to be made on my behalf by AccessPay and acknowledge that AccessPay will charge the first fee of
$7.20 on 30 December 2010.

   Signature:                                                           Dated:
      We will accept an
       unsigned email

NOTE: It is your responsibility to notify AccessPay immediately of any changes to this authority.

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