Notice of intent to claim or vary a deduction
for personal super contributions
COMPLETING THIS STATEMENT
Print clearly using a black pen only. The instructions contain important information about
Use BLOCK LETTERS and print one character per box. completing this notice. Refer to them for more information
about how to complete and lodge this notice.
Place X in ALL applicable boxes.
Section A: Your details
8 9 6 0 3 3 6 6 1 3
The ATO does not collect this information provided on this form. This form is to assist you in providing details to your
Superannuation
Industry (Supervision) Act 1993 Income Tax Assessment Act 1997 and the Taxation Administration Act 1953. It is not an
you
contact the entity you are providing this form to.
2 Name
Title: Mr Mrs / Miss Ms Other
T A M G M A
Other given names
H A N N A H
Day Month
3 Date of birth 1 8 0 8 1 9 7 5
4 Current postal address
1 2 0 2 / 2 B h e l p s t r e e t
Suburb/town/locality State/territory Postcode
C h a t s w o o d N s w 2 0 6 7
(Australia only) (Australia only)
Country if outside of Australia
S y d n e y
5 Daytime phone number (include area code) 0 4 7 8 7 5 1 1 9 8
Section B: Super fund’s details
6 Fund name
H o s t p l u s
7 Fund Australian business number (ABN)
8 Member account number 8 3 0 7 7 5 8 3 0
W Q G K Z Q 7 y n y
NAT 71121-11.2014 Sensitive (when completed) Page 1
Section C: Contribution details
10 Personal contribution details
Is this notice varying an earlier notice? No /
Original Notice to Claim a Tax Deduction section below.
Variation of previous valid notice of intent section below.
ORIGINAL NOTICE TO CLAIM A TAX DEDUCTION
11 Financial year ended 30 June 20
$ .
,
$ .
a tax deduction ,
Section D: Declaration
This form has a declaration where you say the information in it is correct and complete. Please review the information before you
penalties imposed by taxation law.
INTENTION TO CLAIM A TAX DEDUCTION
Complete this declaration if you have not previously lodged a valid notice with your super fund for these contributions.
I declare that at the time of lodging this notice: I declare that I am lodging this notice at the earlier of either:
I intend to claim the personal contributions stated as a before the end of the day that I lodged my income tax
tax deduction return for the income year in which the personal
I am a current member of the identified super fund contributions were made, or
the identified super fund currently holds these contributions before the end of the income year following the year
and has not begun to pay a superannuation income stream
based in whole or part on these contributions I declare that the information given on this notice is correct
I have not included any of the contributions in an earlier and complete.
valid notice.
Name (Print in BLOCK LETTERS)
H A N N A H T A N G M A
Signature
Date
Day Month
0 2 2 0 2 5
Send your completed notice to your super fund. Do not send it to us. The information on this notice is for you and your
VARIATION OF PREVIOUS VALID NOTICE OF INTENT
14 Financial year ended 30 June 20 2 3
$ .
,
$ .
of intent ,
$ .
deduction ,
Page 2 Sensitive (when completed)
Declaration
This form has a declaration where you sign to indicate that the information in it is correct and complete. Please review the
may be liable to administrative penalties imposed by taxation law.
Complete this declaration if you have already lodged a valid notice with your fund for these contributions and you wish to
reduce the amount stated in that notice.
VARIATION OF PREVIOUS VALID NOTICE OF INTENT
I declare that at the time of lodging this notice: I have not yet lodged my income tax return for the relevant
I intend to claim the personal contributions stated as a tax year and this variation notice is being lodged on or before
deduction 30 June in the financial year following the year in which the
I am a current member of the identified super fund personal contributions were made, or
the identified super fund currently holds these contributions the ATO has disallowed my claim for a deduction for the
and has not begun to pay a superannuation income stream relevant year and this notice reduces the amount stated in
based in whole or part on these contributions. my previous valid notice by the amount that has been
disallowed.
I declare that I wish to vary my previous valid notice for these
contributions by reducing the amount I advised in my I declare that the information given on this notice is correct
previous notice and I confirm that either: and complete.
I have lodged my income tax return for the year in which the
contribution was made, prior to the end of the following
income year, and this variation notice is being lodged before
the end of the day on which the return was lodged, or
Name (Print in BLOCK LETTERS)
H A N N A H T A N G M A
Signature
Date
Day Month
0 2 0 2 2 0 2 5
Send your completed variation notice to your super fund. Do not send it to us. The information on this notice is for you and
Sensitive (when completed) Page 3
