ACTIVE 5. YOUR DECLARATION ‘You must complete tis section you wish tomoke @binging nomination + Itect 95s Pty intod (Ae 88 078003497) (AFSL 983858) 08 Trust or Local Goverent Super (an 289013782) (Active Super 0 itrbute my benefits payable rom Active Super upon my death ‘sccordance wit my fing nomination + tupderstana tot + this nomination is nly vai for toe (3) years rom the date of signing, or unt replace or revoke the ‘nomination (by delivering to Active Super anew signed ond dated tom), + thisnomination wll only bo val iho enairas sted oe my spouse ei nancial dependan,© ‘Berson with whom have an intciependency relationship or egal personal represenstve when ond + !fthisnomnaion's inva or has not been recoived by the Tae boar, my death bene wil be ois atthe Tustoe'scacetion to one oe more af my depandont ar lego! persona representatives). + thaveread the iniormation within hie form and understand the tems on which tis nominations made. “+ decree information proviedis tt and eorect hove read the Privacy Collcton Statement and understand how Activ Super ll use the personal Information provided on tir, Name Kevin Sonn RoBsoW signed Ape oatefoounrnd 7 OF 6 BR 6. WITNESS DECLARATION ‘Laswitners, slam and sincerely declare that am over elghteun (18) years. age and that the ‘nomination wasslgned nm presence. wines hatname Heicsan Skins Signed VE oacoommm) 1 OIE RQ, wuness2 Sosa Susan ALLEN Signed Mwrthenr parofoomm | OF er ‘SEND YOUR COMPLETED FORM BACK TO US AT: Mail Active Supot PO Box NB35, Grosvenor Place NSW 220 Email You can emo your signed and winessed orm tos at adminguactivetupercomu, However YOu ‘ls need to post the erga oem ass oqured for proot fiery. ‘acy Catecton stata {ne normatin pron on nso cle ots Py uted (AN 807 347) oar oe Gover Sup (AD 2802722 (At per or {Perot be blo peor ve sacs Yow parton maybe shares wth arse ster apeentcte tee anteaters oer ‘Bote roy car nso a nay pra inmates arte aie toe Wey ‘Sathow ne ute wlomaton wens boat au how Youcot acces ona Sere conan how foureoy appa abe beech eesy eat pen ‘sng recy alt angers on omg ‘ssc 8 yee (8 68 07803 47) AE 8985) 08 rare oral Gomer Spr (AM 2602732) ave Supe). GETIN TOUCH € 1200547873 8:300m-6.00pm (Mon-Fri) @ hello@activesupercom.ay wactivesupercomau Page Sof 5mee 4