Form 3—Request to trustee by non‑member Form 3—Request to trustee by non‑member spouse for payment, as lump sum, of all or part of adjusted base amount

## Form 3—Request to trustee by non‑member spouse for payment, as lump sum, of all or part of adjusted base amount (regulations 52 and 53) REQUEST TO TRUSTEE BY NON‑MEMBER SPOUSE FOR PAYMENT, AS LUMP SUM, OF ALL OR PART OF ADJUSTED BASE AMOUNT TO the trustee of \[name of eligible superannuation plan\]: IN RELATION TO the payment split, of which you were notified on \[date when superannuation agreement, flag lifting agreement or splitting order was served on the trustee\], in respect of the superannuation interest of \[name of member spouse\], date of birth \[date of birth of member spouse\] I, \[name\], the non‑member spouse in relation to the above superannuation interest, of \[postal address\], born on \[date of birth\], request that I be paid, as a lump sum, \*the whole/\*a specified proportion, being \[specify the proportion that is to be paid as a lump sum\], of the amount of the adjusted base amount applicable to me. DATED: \[signature of non‑member spouse\] \* Omit if not applicable