I _______________________________________________________________________

MIN ________________________ authorise my Inmate Account balance to be released as per the

below instructions.

For EFT Transfer

Name of bank:__________________________________________

BSB Number (6 digits)____________________________________

Bank Account Number:___________________________________

Bank Account Name:_____________________________________

If you do not have an active bank account, please provide an address for a cheque to be
forwarded to (this can take 4-6 weeks)

Street Address:__________________________________________________

Suburb/Town____________________________________________________

State (please circle): ACT NSW VIC QLD WA SA TAS NT

Postcode:______________________________

Signed:_________________________________ Print Name:_______________________

Contact No:_______________________________

Witness Signature & Serial No (If completed at Correctional Centre):

_______________________________________________________

Please return this completed form with Photo ID (Release Certificate or Driver’s Licence) to:

goulburnccadmin@justice.nsw.gov.au (Attention: Inmate Accounts)