SECURE PARTY APPLICATION FORM

COLLECTION OF PERSONAL DATA

Strawman Number: 001SPAF (Admin Only) (Initals 001SPAF)No Abbreviations, All in Capitals. Please Type all DataWoman:Hm Address:Postal Address:Bus Address:Email Address:Phone Number:Business Number:Mobile Number:Mobile Number:

Date of Birth:Birth Certificate Original Print Out must be on security paperBirth Certificate Registration No:Birth Certificate Data Print Out Looks like a data sheetBirth Certificate Reference No:Birth Certificate Source Document Birth Certificate Reference No:Passport Aust Registration CopyPassport Aust Registration No:Passport NZ Registration CopyPassport NZ Registration No:Citizenship Registration CopyCitizenship Registration No:Marriage Certificate CopyMarriage Certificate No:Tax File No:Drivers Licence No:Centrelink No:Medicare No:

Husband

Child.1

Child 2.

Child 3.

Child 4.

Dog 1.

Health InsuranceMembership NoHCF Address

HCF Phone No

1 JH20130815.SPF 001 – Secure Party Application Form

SECURE PARTY APPLICATION FORM

HCF Fax NoEmailABNCopy of DocumentService TypeMembership from:

SuperannuationMembership NoMLC Address

MLC Phone NoMLC Fax NoMLC EmailMLC Nominees Pty Ltd ABNThe Universal Super SchemeCopy of DocumentService TypeMembership from:AmountCopy of Statement

SuperannuationMembership NoAddressPhone NoFax NoEmailABNCopy of DocumentService TypeMembership from:AmountCopy of Statement

SuperannuationMembership NoAddressPhone NoEmailABNCopy of DocumentService TypeMembership from:AmountCopy of Statement

House 1. Address:Plan No:Date of purchaseLocal Council AreaLocal Council AddressLocal Council ABNStateCouncil Customer No:Council Customer Ref No:Water CompanyWater Company ABNAccount No:

2 JH20130815.SPF 001 – Secure Party Application Form

SECURE PARTY APPLICATION FORM

Mortgage House 1.Mortgage Loan No:Mortgage CompanyMortgage Company ABNMortgage Company AddressMortgage Company Phone NoMortgage Company Fax NumberCredit Licence No:BalanceCopy of Statement

Bank Account 1Bank Account NameBank Account NameBank Account NameBranch NumberAccount NumberType of AccountCard TypeBank AddressBank PhoneBank ABNBank Credit LicenceCard NameCard HolderCard NumberCopy

Bank Account 2Bank Account NameBranch NumberAccount NumberType of AccountCard TypeBank AddressBank PhoneBank ABNBank Credit LicenceCard NameCard HolderCard NumberCopy

Bank Account 3Bank Account NameBranch NumberAccount NumberType of AccountCard TypeBank AddressBank PhoneBank ABNBank Credit LicenceCard NameCopy

Bank Account 4Bank Account Name

3 JH20130815.SPF 001 – Secure Party Application Form

SECURE PARTY APPLICATION FORM

Branch NumberAccount NumberType of AccountCard TypeBank AddressBank PhoneBank ABNBank Credit LicenceCard NameCard HolderCard NumberCopy

Bank Account 5Bank Account NameBranch NumberAccount NumberType of AccountCard TypeBank AddressBank PhoneBank ABNBank Credit LicenceCard NameCard HolderCard NumberCopy

Bank Account 6Bank Account NameBranch NumberAccount NumberType of AccountCard TypeBank AddressBank PhoneBank ABNBank Credit LicenceCard NameCard HolderCard NumberCopy

Bank Account 7Bank Account NameBranch NumberAccount NumberType of AccountCard TypeBank AddressBank PhoneBank ABNBank Credit LicenceCard NameCard HolderCard NumberCopy

Bank Account 8

4 JH20130815.SPF 001 – Secure Party Application Form

SECURE PARTY APPLICATION FORM

Bank Account NameBranch NumberAccount NumberType of AccountCard TypeBank AddressBank PhoneBank ABNCopy

Phone Account 1 – No:Phone Account NameType of AccountCustomer NumberPhone Company NamePhone Company AddressPhone Company ABN

Phone Account 2 – No:Phone Account NameType of AccountCustomer NumberPhone Company NamePhone Company AddressPhone Company ABNCopy

Phone Account 3 – No:Phone Account NameType of AccountCustomer NumberPhone Company NamePhone Company AddressPhone Company ABNCopy

Website ManagementInternet Account NameType of AccountCustomer NumberAmount:Period

Paypal AccountPaypal Account NamePaypal Account NameType of AccountCustomer NumberPaypal Company ABN

COMPANYTrading NameABNACNTFNCompany AddressPostal AddressYour PositionOffice of Fair Trading - State

5 JH20130815.SPF 001 – Secure Party Application Form

SECURE PARTY APPLICATION FORM

Tenancy Agreement start dateLandlord Name(s)Landlord AddressRental Bond Ref No:Date Commenced TradingDomain NameDomain WebsiteDomain EmailElectricity CompanyElectricity Company ABNElectricity Company No:Copy

COMPANYTrading NameABNACNCompany AddressPostal AddressYour PositionOffice of Fair Trading - StateCopy

COMPANYTrading NameABNACNCompany AddressPostal AddressYour PositionOffice of Fair Trading - StateCopy

COMPANYTrading NameABNACNCompany AddressPostal AddressYour PositionOffice of Fair Trading - StateCopy

CORPORATIONCorporation NoRegistration DateCEOGOVERNMENT DEPTDelegate of the RegistrarOffice of Registrar ABNAddressCopy

TRUST DEED

Order NoACNBeneficiariesDate Commenced

6 JH20130815.SPF 001 – Secure Party Application Form

SECURE PARTY APPLICATION FORM

Copy

TRUST DEED

Order NoACNBeneficiariesDate CommencedCopy

ATO DebtAccount NoAddressDeputy Commissioner of TaxationATO CodeEFT CodeDebtCopy

Lawyer DebtAccount NameAccount NoAddressAddressPhoneLawyer in NameDebtCopy

Credit Card DebtAccount NameAccount NoAddressAddressPhoneManager NameDebtCopy

Credit Card DebtAccount NameAccount NoAddressAddressPhoneManager NameDebtCopy

Website Management DebtInternet Account NameCustomer NumberAmount:

1. Declaration of Sovereignty (DS) [Intials DOB Form Code]2. Deed of Evidence (DE)3. Notice of Understanding and Intent and Claim of Right (COR)4. Security Agreement (SA)

7 JH20130815.SPF 001 – Secure Party Application Form

SECURE PARTY APPLICATION FORM

5. Private Agreement (PA)6. Hold Harmless Indemnity Agreement (HHIA)7. Common Law Copyright Notice (CN)8. Notice of Communication (NC)9. Notice of Fee Schedule (FS)10. Cease and Desist11. Letter of Rogatory12. Affidavit13. Certificate of Protest14. Certificate of Mailing15. Oath and Bond

8 JH20130815.SPF 001 – Secure Party Application Form