Client bank details form

Use this form to provide or change bank details to receive TAC payments by Electronic Funds Transfer (EFT).
Please notify the TAC immediately if you change your bank account details.
This form is for use by TAC clients, their Authorised Representatives, or legal guardian (if the TAC client is a minor). It can also be used by VCAT appointed financial guardians/administrators of TAC client

Client details

First name *

Last name *

TAC claim number *

Email * Note: Using email is not always secure. Information sent via unencrypted email may be at risk of being intercepted, read or modified. By providing us with your email address you acknowledge these risks and agree that the TAC will communicate with you via email.

Phone *

Date of Birth *

Address *

Suburb *

Postcode *

I want to *

Provide my bank account details for the first time
Change my bank account details

Bank Account Details Complete this section to provide your bank account details for the first time OR to change your details to a new account.

Account in the name(s) of *

Name of bank or financial institution *

BSB * (maximum of 6 numbers)

Account number * (maximum of 9 numbers)

For international bank accounts only

Is this an international account? *

IBAN:

SWIFT code/BIC:

BSB/Short code/Branch code:

Branch name:

Branch Address

Branch Suburb

Branch postcode/zipcode

Previously Nominated Account Complete this additional section only if you are changing your bank account details. This is your previous account.

Account in the name(s) of

Name of bank or financial institution

BSB (maximum of 6 numbers)

Account number (maximum of 9 numbers)

Most recent payment

As a security measure, please provide details of the most recent payment you have received from the TAC.

Date

Amount

Description of payment received

Authorisation

Please pay my TAC payments into this account until further notice.

Disclaimer *

I declare that the details I have provided on this form are true and correct. I understand that it is an offence under the legislation to provide false or misleading information.

Your signature *

Printed Name *

Date *

If you are not the TAC Client and are completing this form, please indicate your relationship to the TAC Client (e.g. Authorised Representative, financial administrator, parent, legal guardian).

Relationship to client

Your privacy

The TAC will use this information only for the purposes of making payments. Without this information we will not be able to make EFT payments to you. For more information, please see our Privacy policy.