Change of name

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					                                                                                                                   Change of name

Dear Plan Owner,
We have been advised that you recently changed your name.
Please complete this form, attach the required documentation and return to the office of issue as noted below.
Plan number

Address for notice (if different from that shown above)
Street number and name                                                Town/Suburb                                State    Postcode

     Change of name by marriage
     ∙    Certified copy of Marriage Certificate
     ∙    Change of name form
     Change of name by Deed Poll/Registered
     ∙    Certified copy of document evidencing the registration of change of name (Deed Poll)
     ∙    Change of name form
     Change of name (not Registered no Deed Poll)
     ∙    Statutory Declaration (see over)
     ∙    Copy of current driver’s licence, medicare card or credit cards showing new name
     ∙    Change of name form
     Change of name by adoption
     ∙    Statutory Declaration (see over)
     ∙    Certified copy of Adoption Certificate
     ∙    Change of name form
Full former name
Title        Surname                                                             Given name(s)

Present name
Title        Surname                                                             Given name(s)

Preferred title
     Mr       Mrs        Miss       Ms       Other   please specify
Former signature                                                             Present signature
 X                                                                           X

The National Mutual Life Association of Australasia Limited ABN 72 004 020 437 AFS Licence No. 234649
N.M. Superannuation Pty Ltd ABN 31 008 428 322 AFS Licence No. 234654
Member of the Global AXA Group
Registered Office: 750 Collins Street Docklands VIC 3008                                                                                                                       1
                                                                                                         Statutory Declaration

Change of name – Insurance

1 I was born on           /   /
2 My name registered on my birth certificate was (former name):

3 I have subsequently changed my name to (current name):

     and I am known by this name.

4 I certify that I am the owner of Plan number

     or Member number

     of (Name of Fund)

     issued in the name of (former name)
5 I request (N.M./N.M. Superannuation etc) to alter its records to show my new name.

I acknowledge that this declaration is true and correct and I make it in the belief that a person making a false declaration is liable to the
penalties of perjury.

Declared at

this                                                           day of
Signature of declarant
Signature of witness
Title of witness


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