This is an HTML version of an attachment to the Freedom of Information request 'Online Superannuation Breach Notification Form'.

FORM BRSE 
01/14
Notification by RSE licensee 
Section 29JA Superannuation Industry (Supervision) Act 1993 (SIS Act) 
All questions in the form must be completed before it can be accepted
(See over page for information on completing this form - attach extra pages if insufficient 
space) 
Name  of  the  RSE  licensee                                                                          
RSE licensee ABN
Names of all RSEs affected 
by breach                     
RSE Trust ABN
 
RSE Licence conditions breached         
s. 29E of the SIS Act  (legislative conditions) (select applicable licence condition from list 
below)
29E(1)(a)   RSE licensee law
29E(1)(b)   Trustee duties properly performed
29E(1)(ba)  Trustee must have an ABN or made an application for an ABN that  
 
has not been refused
29E(1)(d)   RSE must be registered
29E(1)(ea)   RSE must have ABN
29E(1)(f)   Notify change in composition
29E(1)(g)   Comply with conditions prescribed by SIS Regulations
Continued on the next page
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FORM BRSE 
01/14
RSE Licence conditions breached (continued)
29E(3)   Public Offer Entity must be constitutional corporation 
29E(4)  Only providing old-age pensions
29E(5)  Minimum number of individual trustees
29E(6)  Transferee fund obligations
29E(6A)  s. 29TC MySuper requirements
29E(6B)  Giving effect to MySuper elections
29E(6C)   ERF elections
29E(6D)  ERF requirements
29E(6E)   Identify multiple super accounts
s. 29EA of the SIS Act (APRA imposed) (select applicable licence condition from the list below)
Public Offer, Extended Public Offer &  
Non-Public Offer licensees
Acting Trustee licensees
1 Notifying change in controlling influence
2 Notifying change in name of RSE Licensee   Specific condition (insert condition no.)
or MySuper product
Specific condition (insert condition no.)
Continued on the next page
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FORM BRSE 
01/14
Legislative Provisions breached  
(insert section/regulation reference – e.g. s.52(2)(f), r. 4.08)
SIS Act 1993 (insert section reference)
SIS Regulations 1994
Corporations Act 2001
Corporations Regulations 2001
Financial Sector (Collection of Data) Act 2001          
Financial Institutions Supervisory Levies Collection 

Act 1998    
Superannuation Prudential Standards
SPS 114 Operational Risk Financial Requirement (ORFR)
SPS 160 Defined Benefit Matters
SPS 220 Risk Management
CPS 226 Margining and risk mitigation for non-centrally cleared derivatives
SPS 231 Outsourcing
SPS 232 Business Continuity Management
SPS 250 Insurance in Superannuation
SPS 310 Audit and Related Matters
SPS 410 MySuper Transition
SPS 450 Eligible Rollover Fund (ERF) Transition
SPS 510 Governance
SPS 520 Fit and Proper
SPS 521 Conflicts of Interest
SPS 530 Investment Governance
Continued on the next page
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FORM BRSE 
01/14
Nature and impact of the breach (including details on the effect on members or account 
holders) and how the breach was identified (use an attachment to this form if necessary)
Date the breach occurred (or will occur) 
D
D
M
M
Y
Y
Y
Y
(Date ranges are not acceptable)
/
/
Date trustee became aware of breach  
D
D
M
M
Y
Y
Y
Y
(Date ranges are not acceptable)
/
/
Estimated Number of members/account holders 
affected
Estimate of $dollar amount involved  
(Amount range is not acceptable)
$
Category of Breach  
(Please select only ONE of the following categories that best describes the nature of the breach)
Adequacy of resources
Audit/Actuarial or reporting
Business continuity management
Contribution standards
Defined benefit matters
Disclosure
Fit and proper
Governance, remuneration or conflict management
Insurance in superannuation
Investment governance or valuation
Management of reserves
MySuper/ERF requirements
ORFR requirements
Outsourcing
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FORM BRSE 
01/14
Payment standards
Risk management
Sole purpose test
Trustee covenants
Unit pricing
Other
Rectification action already undertaken and/or proposed action  
(use an attachment to this form if necessary) 
Whether ASIC has been separately notified of breach  
Yes
No
Contact Person in relation to breach
First name
Last name
Phone number
Return address for APRA 
acknowledgment of notification 
(email, fax or postal address)
Position held with RSE licensee
Date
D
D
M
M
Y
Y
Y
Y
/
/
End of form.
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FORM BRSE 
01/14
Email      Email form directly to your APRA Responsible Supervisor’s email address 
Fax to     02 9210 3411   
Post to   GPO Box 9836, in your Capital City
APRA will acknowledge receipt of this breach notification.
(Refer to Notes on completing this form overleaf)
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FORM BRSE 
01/14
Your obligations
Reporting breaches to ASIC
If an APRA-regulated institution becomes 
Breaches under APRA administered 
aware it has breached (or will breach) 
legislation may also breach ASIC-
a prudential requirement, it may have 
administered legislation.  You should 
obligations to report the breach to APRA. 
determine if you are also required to report 
The relevant legislative requirements for 
the breach to ASIC. 
reporting breaches are found in the Prudential  If you use the Online Breach Notification 
Acts.
System to report your breach, you can elect 
•  s. 62A of the Banking Act 1959
for APRA to pass it on to ASIC, fulfilling your 
reporting obligations. If you notify APRA of your 
•  s. 38AA of the Insurance Act 1973
breach using this form, you must report your 
•   s. 132A of the Life Insurance Act 1995
breach separately and directly to ASIC. 
•  s. 29JA of the Superannuation Industry 
You cannot use the Online System or forms 
(Supervision) Act 1993
to report a breach that relates solely to ASIC-
administered legislation.  You should refer 
When must you notify APRA?
to ASIC to ascertain how to report these 
breaches.
Some breaches or matters must be reported 
immediately to APRA in writing.
Enquiries
Other significant breaches or matters must 
Telephone 1300 55 88 49
be reported to APRA in writing within 10 
Email  [email address] 
business days of becoming aware that a 
breach has occurred or will occur.
Mail 
GPO Box 9836 
Refer to the relevant legislation to determine 
in all capital cities  
whether a breach or matter needs to be 
(except Hobart and Darwin)
reported and for the required timeframe.
Failure to notify APRA of a breach
Disclaimer
The purpose of these instructions is to 
Failure to notify APRA of a breach within the 
provide general assistance in the use of the 
required time frame is an offence under each 
APRA online breach reporting system. These 
relevant Act.
instructions do not contain any legal advice 
and APRA disclaims any and all liability 
Format of Breach Notification
or responsibility for any loss or damages 
Breach notification must be in writing.
arising out of any use of, or reliance on, 
these instructions or the APRA online breach 
For ease of reporting, APRA has made 
reporting system. Users of the APRA online 
available an Online Breach Notification 
breach reporting system are encouraged to 
System. Alternatively you may use this form 
obtain professional advice on their breach 
and send to APRA. APRA prefers institutions 
reporting obligations under the relevant 
to use the Online System. 
legislation and to exercise their own skill and 
care in relation to any material contained in 
these instructions or in the APRA.
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