Bank Account Application Form – Netherlands

ISSBON2 Bank Account App#1BF79B 24/1/06 12:47 PM Page 1

Application and Authority for a Special Purpose Bank Account

Bank Account Application

Form – Netherlands

(“The account”) for receipt of Government of the Netherlands Pension payments and transfer of equivalent

amounts to Work and Income.

I request Westpac Banking Corporation (Westpac) to open a special purpose bank account for me which will be

free of bank charges. I instruct and authorise Westpac to operate the account on the following terms and conditions:

a) The account will be used solely for the receipt of my Government of the Netherlands Pension payments and

the transfer of equivalent amounts of those payments to Work and Income of the New Zealand Government.

If I attempt to use the account for any other purpose, Westpac must transfer the credit balance in the account

to Work and Income and close the account.

b) Westpac is instructed and authorised to transfer the balance of the account to Work and Income at any frequency

agreed between Westpac and Work and Income.

c) Except for transfers of the equivalent amounts of Government of the Netherlands Pension payments to Work

and Income no withdrawals will be permitted from the account.

d) No cheque or deposit books will be issued and I will not be permitted to nominate the account for credit card,

telephone, EFTPOS, automatic teller machine, or any other type of transaction.

e) Westpac is authorised to disclose any information about me or the account, including payments of

my Government of the Netherlands Pension, to Work and Income or the Government of the Netherlands or

both, where this is necessary to facilitate the administration of the alternative arrangement with the Chief

Executive, Ministry of Social Development or the account.

f) Westpac will not disclose that account number to me.

g) Bank account statements will not be issued to me by Westpac, except where required for audit purposes or

dispute resolution.

h) All instructions, inquiries and notices must be addressed to Westpac branch at 260 Lambton Quay, Wellington

(or such other place as Westpac from time to time notifies me), and must state my full name, my Work and

Income client number, and my full address. Westpac’s other branches will not be in a position to accept

instructions or notices or to answer inquiries regarding the account.

i) In the event that Work and Income notifies Westpac it has terminated the alternative arrangement with me,

or that the alternative arrangement has ceased, Westpac must transfer the balance in the account to Work and

Income (except where I have been adjudicated bankrupt) and close the account.

j) I may request Westpac to close the account at any time, but Westpac is instructed and authorised to transfer

any monies in the account, including the equivalent amounts of the Government of the Netherlands Pension

payments received between the time I make the request and the time the account is closed, to Work and

Income when it closes the account. I will not be permitted to withdraw any monies in the account before it is

closed.

k) If I revoke this authority, or my authority to the Government of the Netherlands to pay my Government of the

Netherlands Pension to the account, the Westpac must, on receiving notice of the revocation, transfer any

monies in the account and close the account in accordance with paragraph(j) with effect from the date the

revocation of authority takes effect.

l) In the event that Westpac is advised by any means which it is reasonable to relay, of my death or ceasing to

reside in New Zealand, Westpac is authorised to transfer the balance in the account to Work and Income and

close the account.

m) If Westpac closes the account, Westpac will not advise me but must advise Work and Income and request Work

and Income to communicate the closure and reasons to me.

n) If any Government of the Netherlands Pension payments are received for credit of the account after it is closed,

Westpac will return these to the Government of the Netherlands with the explanation ‘account closed’.

o) Nothing in this document or my arrangements with Westpac or Work and Income constitutes an assignment

of my Government of the Netherlands Pension to Westpac or Work and Income.