CLAIM FOR PAYMENT OF UNCLAIMED MONEYS – ON BEHALF OF DECEASED
Public Trustee for the ACT, PO BOX 221, Civic Square ACT 2608
AUSTRALIAN CAPITAL TERRITORY
UNCLAIMED MONEYS ACT 1950
1.
Claimant’s full name (Block letters)
2.
Deceased’s full name (Block letters)
3.
Authority to Act (Grant of Probate / Letters of Administration – Attach copy)
4.
Relation of Claimant to Deceased
5.
Current Residential Address
6.
Postal Address (If different from residential address)
7.
Contact phone number/s.
8.
Date of Birth of Deceased
(
9.
)
Name and Address of Company who held moneys on Deceased’s behalf
10.
Deceased’s address at that time
11.
Account/Policy or Reference No.
12. Deceased’s Tax File Number (Super only)
13.
If Claiming Superannuation Moneys, please state last known employer’s name and address
14.
Amount of money claimed
$
15.
Tick the appropriate box; Please post a cheque to my address, or Please post a cheque to my agent, or I authorise the Public Trustee’s Office to deposit funds directly into the following bank; Bank Account Name BSB No.
-
Account Number
16.
Declaration
I,…………………………………………………………………………………… of…………………………………………………………………………………… make the following declaration under the Statutory Declarations Act 1959: The deceased is entitled to the moneys in Item 14 previously held by the company described in item 9; The money claimed is payable to the estate under the Unclaimed Moneys Act 1950; and To the best of my knowledge and belief, the estate has a true and valid claim to the moneys described in this application. The funds remain outstanding and the deceased or the estate has not received the funds previously. I make this solemn declaration by virtue of the Statutory Declarations Act 1959 and subject to the penalties provided by that Act for making of false statements in Statutory Declarations, conscientiously believing the statements contained in this declaration to be true in ever particular. ………………………….. Declarant’s Signature ………………………. Date ……………………………………………. Witness’ Signature …………………………………………….
Full name, qualification and address of person before whom the declaration is made (in printed letters)
…………………………………………….
Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years — see section 11 of the Statutory Declarations Act 1959. Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see section 5A of the Statutory Declarations Act 1959.
This claim form requires supporting Documentation. Please use the attached checklist.
CLAIM FOR PAYMENT OF UNCLAIMED MONEYS - ON BEHALF OF DECEASED
Public Trustee for the ACT, PO Box 221 Civic Square ACT 2608
AUSTRALIAN CAPITAL TERRITORY
UNCLAIMED MONEYS ACT 1950
CHECKLIST FOR LODGING YOUR CLAIM
This checklist is designed to help you fill out your claim form and to ensure that all supporting documentation is supplied. A claim that has all the required documentation could still take up to two weeks to approve, therefore to ensure that your claim is handled as quickly as possible please ensure all of the following is met:
If you are claiming for Superannuation Moneys you must supply the Tax File Number of the Deceased. If this is not supplied a tax deduction will have to be withheld up to 45% of the total. If you do not have the TFN then please contact the Australian Taxation Office on 13 28 61. Please ensure that the Declaration on Page 2 of the claim form is signed, dated and witnessed by someone authorised to do so, such as a Justice of the Peace, Solicitor, Post Master, Police Officer, Medical Practitioner, Pharmacist, Bank Manager, or Registered Accountant. For identification purposes please supply a certified copy of the Deceased’s Licence, Passport or Birth Certificate and a certified copy of your Drivers’ Licence, Passport or Birth Certificate. Please provide a certified copy of documentation in the name of the deceased that matches the last known address related to the amount, such as a bank statement or electricity bill. If available, please supply certified copies of the last Policy Statement or Certificate received by the deceased relating to the amount. Please supply a certified copy of the Grant of Probate or Grant of Letters of Administration. If a Grant of Probate or Letters of Administration are unavailable please contact our office. If there has been any name changes of the deceased or widow/er since the amount was lodged, please supply evidence of these changes, that is, Name Change Certificates or Marriage Certificates. Please double check to make sure all copies of documentation have been certified by someone authorised to do so, such as a Justice of the Peace, Solicitor, Post Master, Police Officer, Medical Practitioner, Pharmacist, Bank Manager, or Registered Accountant. When all the above requirements are available, please lodge the claim with our office at: Public Trustee for the ACT PO Box 221 CIVIC SQUARE ACT 2608