This data sheet can be used to request a triennial actuarial valuation for a defined benefit self-managed superannuation fund. Our report will also include the Benefit Certificate and the Funding/Solvency Certificate needed by the Superannuation Guarantee legislation. The Trustees of the Fund may also need to complete Allocated/Lifetime Pension Certificates and Notional Surchargeable Contribution requests (if relevant).

Fund Administrator / Advisor Details

Where would you like the certificate returned to and who should be contacted if there are any queries:

Name:
Company:
Address:
Post Code:
Phone:	(      )
Fax:	(      )
Email:

Fund Identification Details

Please ensure the name of the fund is exactly as set out in the trust deed e.g. Superannuation Fund not Super Fund, etc. The names of individual trustees should be in full, no initials. If the trustee is a company please include ACN/ABN number.

Name of Fund:
Full Names of Trustees:
Address of Trustees:
Date Fund Established:

Membership and Type of Benefit Details

Number of members in the Fund at calculation date of _____/_____/200__:

1 Member     2 Members     3 Members     4 Members    

Type of current benefits: (Please tick applicable)

	Member 1	Member 2	Member 3	Member 4
Contributory Member
Lifetime Pension Member
Allocated Pension Member

Membership Information

Item	Member 1	Member 2	Member 3	Member 4
Name
Sex
Date of Birth
Membership Date
Joined Company Date
Salary Calc Date
Salary 1 Year Earlier

Attachment Checklist

Please check that you have copies of the following documents to send with this request:

		Previous actuarial report
		Balance Sheet and Operating Statement
		Benefit specification section of Deed (or whole Deed)
		SG Benefit and Solvency Certificates
		Account Balance information (if relevant to benefit design)

Comments:

Actuarial Fees

Report and Certificates: $660.00 plus $60 per additional member (inclusive of GST)
Invoices will be forwarded with report.

Please forward this document and any attachments to Brian Bendzulla at:
Bendzulla Actuarial Pty Ltd, GPO Box 1181, Hobart TAS 7001
Fax 1800 103 123   Tel 1800 203 123
Email: actuarial@bendzulla.com  

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