Professional Documents
Culture Documents
Form
1194
Note: If you are using the free ATO online DASP service, your
eligibility is verified online, confirming that your Temporary
Resident visa has ceased to be in effect and that you have left
Australia.
Charges
Method of payment
In Australia
To make a payment, please pay by credit card, debit card, bank
cheque or money order (made payable in Australian dollars) to
the Department of Immigration and Border Protection. Debit
card and credit card are the preferred methods of payment.
Outside Australia
Before making a payment outside Australia, please check with
the Australian Government office where you intend to make
the payment as to what methods of payment and currencies
they can accept and to whom the payment should be made
payable.
Send this form, together with the receipt of payment, to:
Department of Immigration and Border Protection
Superannuation Certification and Cancellation Team
GPO Box 1496
HOBART TAS 7001
AUSTRALIA
Form
Please use a pen, and write neatly in English using BLOCK LETTERS.
Tick where applicable
Sex
Date of birth
Country of birth
Country of
citizenship
Female
Male
DAY
No
Given names
Yes
1194
MONTH
YEAR
Family name
POSTCODE
Given names
10 Telephone numbers
COUNTRY CODE
AREA CODE
NUMBER
Deed poll
Office hours
) (
Marriage
After hours
) (
Other
Evidence of any name changes must be provided, eg. marriage certificate,
deed poll evidence, etc. (All documents MUST be certified copies)
Yes
No
Fax number
Yes
Give details
COUNTRY CODE
Give details
AREA CODE
) (
NUMBER
)
Email address
Family name
Given names
Reason for change:
Deed poll
No
Go to Part C
Yes
Go to Part B
Marriage
Other
If you have been known by any names other than these names, please
provide documentary evidence. (All documents MUST be certified copies)
2. Fund name
Fund address
MONTH
YEAR
POSTCODE
Flight number/
name of ship (if known)
Passport number when
you arrived in Australia
MONTH
17 Payment details
YEAR
Place of departure
Flight number/
name of ship (if known)
Passport number when
you departed Australia
15 If you arrived as a child (under 18) and no longer hold the passport or travel
document you used on your first arrival, please give the following details
Parents full name
MONTH
Money order
YEAR
Female
Male
Credit card
Australian Dollars
MasterCard
Diners Club
American Express
JCB
AUD
Visa
DAY
MONTH
YEAR
Debit card
Female
MONTH
YEAR
Expiry date
Cardholders name
1. Fund name
COUNTRY CODE
Telephone
number
Fund address
AREA CODE
) (
NUMBER
)
Address
POSTCODE
POSTCODE
Credit card information will be used for charge paying purposes only.
Go to Part D
Yes
Go to Part C
Cancellation procedures
You should note that:
a request for visa cancellation made on this form will only be
considered in respect of eligible Temporary Resident visas;
requesting cancellation of a current eligible Temporary Resident visa
is entirely optional;
visa cancellation decisions will be made under Section 128 of the
Migration Act 1958;
visa cancellation under Section 128 of the Migration Act 1958 is
discretionary;
visa cancellation can only be considered under Section 128 of the
Migration Act 1958 where the visa holder is outside Australia;
if your visa is cancelled, the Migration Act 1958 requires that you be
sent a notice stating the grounds for cancellation;
there is no fee payable for visa cancellation.
Name of visa
subclass
Visa grant number
(if known)
DAY
MONTH
YEAR
MONTH
YEAR
Date of birth
Passport number when they arrived in Australia on
the Temporary Resident visa
Subclass of visa
currently held
Name of visa subclass currently held
Date of departure
from Australia
DAY
MONTH
YEAR
DAY
MONTH
YEAR
2. Family name
Given names
Date of birth
Passport number when they arrived in Australia on
the Temporary Resident visa
Subclass of visa
currently held
Name of visa subclass currently held
Visa grant number (if known)
Date of departure
from Australia
DAY
MONTH
YEAR
Declaration
WARNING: Giving false or misleading information is a serious offence.
28 I declare that:
Go to Question 27
Yes
Title:
Mrs
Mr
Miss
Other
Ms
Family name
Given names
Address
POSTCODE
Office hours
AREA CODE
) (
NUMBER
)
Your signature
Mobile/cell
DAY
Authority (MARA)?
MONTH
YEAR
Date
No
Yes
Go to Question 27
We strongly advise that you keep a copy of this form and all
attachments for your records.
No
Yes
26 Did you pay the person/agent and/or give a gift for this assistance?
No
Yes
OR
Migration agent
OR
Exempt person
Name of payer
Amount paid
DAY
Date
Office
Comments
AUD
MONTH
YEAR