Please complete all the details on this form in BLOCK LETTERS using a BLACK PEN and return to Super SA via post or email.
Triple S / Flexible Rollover Product / Income Stream / Super SA Select
DATE OF ISSUE:  NOVEMBER  OFFICIAL: SENSITIVE (when completed) ASFM PAGE  OF 
WFL0010
Client ID:
Transfer your super
To find out more visit supersa.sa.gov.au or call 1300 369 315
1. Personal details
Title Date of birth
D D
/
M M
/
Y Y Y Y
Given Name(s)
Family Name
Email address*
Mobile phone* Work phone* Home phone*
Street address
Suburb State Postcode
Postal address
(if dierent from above)
Suburb State Postcode
2. Tax File Number (TFN)
Providing your TFN will ensure that your entitlement is taxed concessionally.
If you choose not to provide your TFN, part of your entitlement may be taxed
at the highest marginal rate. Declining to provide your TFN is not an offence.
Tax File Number
Checklist
Before Super SA can process your payment you need to complete all sections on this form and provide all requested information.
I have completed my personal details (Section 1).
I have nominated where my entitlement will be transfered to
(Section 4).
I have supplied Super SA with my tax file number (TFN) (Section 2). I have signed the Member Declaration (Section 5).
I have nominated which scheme and the amount to be transferred
(Section 3).
Note:
If you are unsure what benefit is available, please contact Super SA to confirm to avoid delays in
processing your request.
Use this form if you wish to transfer your benefit to another Super SA product or Superannuation fund.
* By providing your email address and/or telephone number(s) you are agreeing to receive, from SuperSA, or an organisation on behalf of SuperSA, marketing
communications including newsletters, announcements, invitations or surveys. You may opt out of these marketing communications at any time by updating your
communication preferences in our online member portal or by contacting SuperSA. If you opt out of marketing communications, you will still receive important account
information from us.
Please complete all the details on this form in BLOCK LETTERS using a BLACK PEN and return to Super SA via post or email.
Triple S / Flexible Rollover Product / Income Stream / Super SA Select
DATE OF ISSUE:  NOVEMBER  OFFICIAL: SENSITIVE (when completed) ASFM PAGE  OF 
Transfer your super
Important Note: Commonwealth preservation rules are dierent from preservation rules in TripleS. You need to be aware of this if you are
rolling money out of TripleS.
3. Indicate your scheme for transfer
Please indicate the amount and scheme for transfer.
TRIPLES MEMBERS Account ID
Transfer
$
Transfer the maximum available while maintaining the minimum balance to keep my account open.
Transfer my full benefit
For members transferring their full benefit to Super SA Select, your account will remain open as any insurance entitlements are provided through
TripleS.No administration fees and costs will be payable in TripleS. For members transferring part of their benefit you are limited to one transfer
perfinancial year.
FLEXIBLE ROLLOVER PRODUCT INVESTORS Account ID
Transfer
$
Transfer the maximum available while maintaining the minimum balance ($6,500) to keep my account open.
Transfer my full benefit
INCOME STREAM INVESTORS Account ID
Transfer
$
Transfer the maximum available while maintaining the minimum balance ($6,500) to keep my account open.
Transfer my full benefit
SUPER SA SELECT Account ID
Transfer
$
Transfer the maximum available while maintaining the minimum balance to keep my account open.
Transfer my full benefit
For partial transfers, the amount remaining in the fund must be greater than $6,500 (or greater than $25,000 for Operational SA
Ambulance employees and active Police Ocers).
For partial transfers, the amount remaining in the fund must be greater than $6,500 (or greater than $25,000 for Operational SA
Ambulance employees andactive Police Ocers).
Important Note: Please call Super SA if you have Surcharge liability before submitting this application.
To retain funds within your TripleS account for payment of your surcharge liability please complete this section and attach acopy of the
relevant notice ofassessment from the ATO to this form.
Retain $ in the TripleS scheme for payment of my surcharge liability when it becomes due.
Please complete all the details on this form in BLOCK LETTERS using a BLACK PEN and return to Super SA via post or email.
Triple S / Flexible Rollover Product / Income Stream / Super SA Select
DATE OF ISSUE:  NOVEMBER  OFFICIAL: SENSITIVE (when completed) ASFM PAGE  OF 
Transfer your super
4. Receiving fund details
Where you would like us to transfer your entitlement to. (Select only 1 option)
Option 1
SUPER SA FLEXIBLE ROLLOVER PRODUCT
I wish to transfer to the Super SA Flexible Rollover Product
(min $1,500) – (If you don't currently have an account, please also
complete an application to Purchase form, available in the Flexible
Rollover Product Disclosure Statement).
Option 3
SUPER SA TRIPLES
I wish to transfer to TripleS – (You must already have an account to
transfer any funds to TripleS)
Option 5
I WISH TO TRANSFER TO THE SUPER PRODUCT
NAMED BELOW:
Name of fund
Super fund member number
Super fund ABN
Super fund USI
Option 2
SUPER SA INCOME STREAM
I wish to transfer to the Super SA Income Stream (min $30,000) –
(Please also complete an application to Purchase form, available inthe
Income Stream Product Disclosure Statement)
Option 4
SUPER SA SELECT
I wish to transfer to Super SA Select – (If you don't currently have
an account, please also complete an application form, available in the
Super SA Select Product Disclosure Statement)
Option 6
I WISH TO TRANSFER TO MY SELF MANAGED
SUPER FUND SMSF.
SMSF name
ABN
Electronic Service Address (ESA)
SMSF bank details (please attach a copy of your most recent SMSF bank statement)
Account name
BSB
–
Account
number
– –
Please complete all the details on this form in BLOCK LETTERS using a BLACK PEN and return to Super SA via post or email.
SSA1467
DATE OF ISSUE:  NOVEMBER  OFFICIAL: SENSITIVE (when completed) ASFM PAGE  OF 
Transfer your super
Contact us
EMAIL [email protected]v.au, or WEBSITE supersa.sa.gov.au PHONE 1300 369 315
POST GPO Box 48, Adelaide SA 5001 MEMBER CENTRE BY APPOINTMENT ONLY 151 Pirie St Adelaide SA 5000
Triple S / Flexible Rollover Product / Income Stream / Super SA Select
5. Member declaration
– I acknowledge that Super SA may verify my details with the Australian
Tax Office (ATO) in order to process this request.
– I declare that the information I have provided on this form is true and
correct and understand that:
• Once my payment has been made I will not be able to change
myinstructions.
• By closing my TripleS, Super SA Select or FRP account in full all
insurance held will cease (unless I am transferring from TripleS to
Super SA Select).
• The unit price used to calculate my payment is the unit price at,
orimmediately prior to, the date of processing the payment.
• I understand that any partial payment will be withdrawn from my
selected investment options:
- TripleS, Super SA Select & FRP - in proportion to the balance
heldineach investment
- Income Stream - as per my current investment drawdown order.
• I understand that partial rollovers will be drawn proportionally
from my tax free and taxable components.
Casual TripleS employee declaration
– I understand that if I am a casual employee who worked nine or
more hours per week, I am taken to remain in employment for a
period of 12 months after the last time I performed work for the
SA public sector.
– Where I close my account I understand that by signing this
declaration I am confirming that I have ceased employment with
the SA public sector and this is a notice to the Board to cease
the12 month period from the date of signing this declaration.
– I understand that by signing this declaration I am terminating
my membership with TripleS and any Total and Permanent
Disablement and/or Death Insurance and Income Protection
Insurance will be cancelled from the date of signing
thisdeclaration.
Signature
Date
D D
/
M M
/
Y Y Y Y