CSC AFSL 238069 RSEL L0001397 ABN 48 882 817 2431922 Scheme

CSS RSE R1004649 ABN 19 415 776 361

DFRB Scheme

MilitarySuper RSE R1000306 ABN 50 925 523 120

DFRDB Scheme ABN 39 798 362 763

PSS RSE R1004595 ABN 74 172 177 893

PNG Scheme

PSSap RSE R1004601 ABN 65 127 917 725

DFSPB

The information provided in this form is general advice only and has been prepared without taking account of your personal objectives, financial situation or needs. Before acting on any such general advice, you should consider the appropriateness of the advice, having regard to your own objectives, financial situation and needs. You may wish to consult a licensed financial advisor. You should obtain a copy of the relevant Product Disclosure Statement (PDS) and consider its contents before making any decision regarding your super.

Commonwealth Superannuation Corporation (CSC) ABN: 48 882 817 243, AFSL: 238069, RSEL: L0001397 Defence Force Retirement and Death Benefits SchemeABN: 39 798 362 763

Australian Defence Force SuperannuationABN: 90 302 247 344 RSE: R1077063

Commonwealth Superannuation SchemeABN: 19 415 776 361 RSE: R1004649

Public Sector Superannuation accumulation planABN: 65 127 917 725 RSE: R1004601

Military Superannuation and Benefits SchemeABN: 50 925 523 120 RSE: R1000306

Australian Defence Force CoverABN: 64 250 674 722

Public Sector Superannuation SchemeABN: 74 172 177 893 RSE: R1004595

1922 Scheme DFRB Scheme PNG Scheme DFSPB CSC retirement income

PSS Application for issue of invalidity retirement certificate

SPC03/19

FOR EMPLOYER

USE

A Member’s detailsReference number (AGS)

Salutation Mr Mrs Ms Miss Other

Surname

Given name(s)

Date of birth We cannot issue an invalidity retirement certificate to PSS customers over age 60

D D M M Y Y Y Y

/ /

Address

SUBURB STATE POSTCODE

PhoneBUSINESS HOURS AFTER HOURS

MOBILE NUMBER

Email

@

All sections to be completed by Employer.

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B Employer’s detailsEmployer’s name

Employer’s address

SUBURB STATE POSTCODE

Case manager surname

Case manager given name(s)

Email

@

Payroll officer name

Phone numberBUSINESS HOURS

Email address

@

Important: Eligibility for pre-assessment payments will be determined by CSC and will be paid from the date that is advised. Payments for pre-assessment will be calculated using the above information. Any errors may cause an underpayment or overpayment in pre-assessment payments to the member.

C Employment and superannuation detailsApplicant is a member of PSS Superannuation Act 1990

Date member started leave for a continuous period because of a serious medical condition.

D D M M Y Y Y Y

/ /

Salary for Superannuation on the above date that continuous leave commenced.

Date on which sick leave payments ceased/will cease.

D D M M Y Y Y Y

/ /

Is member in receipt of compensation benefits for the current condition?

Yes No

Has member applied for compensation benefits?

Yes No

Date on which compensation payments ceased/will cease.

D D M M Y Y Y Y

/ /

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EmailCSS and PSS: employer.service@admin.csc.gov.auPSSap: employers@pssap.com.au

PhoneCSS and PSS: 1300 338 240PSSap: 1300 308 806

FaxCSS and PSS: (02) 6272 9996PSSap: 1300 364 144

Web eac.csc.gov.au

Fax(02) 6272 9613

Emailemployer.service@csc.gov.au

Phone1300 338 240

Fax(02) 6275 7010

PostEmployer ServiceGPO Box 2252Canberra ACT 2601Web

csc.gov.auOverseas Callers+61 2 6275 7000

End Form

D Checklist of attachments to this SPC form Treating doctor’s report dated within last 6 months AMP report dated within last 6 months �nyotherrelevantmedicaldocuments,includingrehabilitationreports,graduatedreturn

toworkreports,andanyothertreatingdoctororindependentspecialistreports Sick leave records Duty statement Recommendation by compensation provider (for all compensation cases) Confidential Medical and Personal Statement (CMAPS) (less than three years contributory service)

E Declaration by case managerI certify that the above information is correct and that the member:

has been provided with information about invalidity retirement and

has been advised that pre–assessment payments will be recovered if compensation payments are granted.

Signature and date

SIGNATUREDate signed

D D M M Y Y Y Y

/ /

F Declaration by payroll officer I certify that the information in Section C Employment and Superannuation details is correct.

Signature and date

SIGNATUREDate signed

D D M M Y Y Y Y

/ /

Important: Member MUST be provided with information about invalidity retirement. Information is available at csc.gov.au

Sign

Sign

Where can I get more information?EMAIL employer.service@csc.gov.auPHONE 1300 338 240FAX (02) 6275 7010MAIL Employer Service GPO Box 2252

Canberra ACT 2601WEB csc.gov.au

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