Form 4—Request to trustee by non‑member Form 4—Request to trustee by non‑member spouse for payment, as lump sum, of all or part of remaining base amount

## Form 4—Request to trustee by non‑member spouse for payment, as lump sum, of all or part of remaining base amount (regulation 58) REQUEST TO TRUSTEE BY NON‑MEMBER SPOUSE FOR PAYMENT, AS LUMP SUM, OF ALL OR PART OF REMAINING 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 \[date of birth\], being entitled to be paid an amount under paragraph 57(2)(a) of the Family Law (Superannuation) Regulations 2001, request that I be paid, as a further lump sum, \*the whole/\*a specified proportion, being \[specify the proportion that is to be paid as a lump sum\], of the remaining base amount allocated to me in relation to the superannuation interest. DATED: \[signature of non‑member spouse\] \* Omit if not applicable