Metal Provident Fund Form – Fill Out and Use This PDF

do hereby make an oath and say:

(i)That the deceased was my (state relationship to deceased); _______________________________________________________________

(ii)That all the information given on this application form is true;

(iii)That I authorise the Fund to deposit any benefits due into my PERSONAL banking account, the details of which are reflected on the BANK MANDATE appearing below.

ATTENTION: PAYMENTS WILL BE DEPOSITED ELECTRONICALLY INTO YOUR PERSONAL BANKING ACCOUNT AS REFLECTED ON THE BANK MANDATE BELOW.

____________________________________

Signature or Mark of Applicant

SIGNED AND SWORN/AFFIRMED BEFORE ME AT _________________________________________________________________________

this _________________________________________ day of __________________________________________________ 20 ________________

The deponent has acknowledged that he/she knows and understands the contents of this document.

_____________________

Commissioner of Oaths

Commissioner of Oaths are available at any Police Station or Post Office or the Office of any attorney or Tribal Chief or Induna. Commissioner’s stamp must be impressed on this form.

MANDATE FOR PAYMENT OF BENEFIT TO BANK

NO ALTERATIONS OR TIPPEX WILL BE ACCEPTED

A.DEPENDANT’S DETAILS

(1)Surname of Dependant

(2)Maiden Name

(3)First Name

(4)Identity Number (Identity Document to be produced)

B. DETAILS OF DEPENDANT’S ACCOUNT - To be verified by Bank official as correct and active/current.

(1)Name of Bank or Building Society

(2)Address of Bank/Building Society

															Postal Code
(3)	Name of Branch
(4)	*Branch Code* (To be supplied by Bank or Building Society)
(5)	Account Number
(6)	Type of Account

	…………………………………….	…………………………………..
		FULL NAMES
	SIGNATURE OF
		OF BANK OFFICIAL
	(ACCOUNT HOLDER)
	…………………………..
	DATE
		SIGNATURE OF OFFICIAL
		AND STAMP OF BANK

NOTE WELL: ANNEXURES ‘A’ – ‘G’ MUST ACCOMPANY THIS APPLICATION FORM.

2.

PENSION AND PROVIDENT FUNDS - FORM 'D'

To be completed by the member's employer in all cases where Form 'A' is applicable and submitted by the Trustee/ Administrator / Insurer of the Fund in conjunction with Form 'A' to the taxpayer's Receiver of Revenue.

	Name of Employer	:	_______________________________________________________
	Address of Employer	:	_______________________________________________________
			_______________________________________________________
1.	Employee's Surname	:	_______________________________________________________
	Employee's First Names	:	_______________________________________________________
	Employee's Identity no.	:	_______________________________________________________
	Employee's Tax no.	:	_______________________________________________________

2.Highest average salary actually earned by the taxpayer during any five consecutive years in the service of the employer during his membership of the Fund.

Year				Salary
20			------------------------------------------------------------- R		p.a.
20			------------------------------------------------------------- R		p.a.
20			------------------------------------------------------------- R		p.a.
20			------------------------------------------------------------- R		p.a.
20			------------------------------------------------------------- R		p.a.

Total	R		______________________
Average for the 5 years or lesser period if employee employed for lesser
period ......................................................................…….	R			.

3.	Twice the salary (Pension Fund) and thrice the salary (Provident Fund)
	during 12 months immediately preceding death	R		.
Note:	For the purpose of questions 2 and 3, "Salary" includes any amount received or receivable annually under
	a contract of service as also cost of living allowances, commission, share of profits, etc., but not occasional
	bonuses or fees which were dependent on the whim of the directors or employer.

Certified correct to the best of my knowledge and belief.

Date:

Manager / Secretary

MIBFA/DEATHS/A/P/mc

4.

ANNEXURE ‘A’

DECEASED’S FULL NAME : _________________________________

ID NO : ________________________

In terms of Section 37 (C) of the Pension Fund’s Act, the following additional information is needed to assist in determining dependants and the distribution of the benefits:

1.Was the deceased previously married? YES ฀ NO ฀. If YES, please supply the name and residential address of the ex-spouse/s and a copy/copies of either the Divorce Order/s or the ex-wife’s Death Certificate/s if applicable.

_____________________________________________________________________________________

_____________________________________________________________________________________

2.If deceased was divorced did he/she remarry after his/her divorce? YES ฀ NO ฀. If YES, please supply the spouses’ name and residential address if different to the spouse mentioned on page 1

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3.Were any children born out of wedlock? YES ฀ NO ฀. If YES, supply details of the children’s names, residential addresses and birth certificates. _____________________________________________________________

________________________________________________________________________

_____________________________________________________________________________________

3.1Name and residential address of children’s guardians and guardian’s relationship to deceased:

________________________________________________________________________________________

________________________________________________________________________________________

4.Was the deceased required to pay any child maintenance? YES ฀ NO ฀. If YES, please supply a certified copy of the Maintenance / Divorce Order.

5.Are any of the deceased’s minor children being cared for by someone other than their mother? YES ฀ NO ฀. If YES, please arrange for guardian to complete Annexure ‘D’ where necessary and provide details of their

names and residential addresses.____________________________________________________________________

______________________________________________________________________________________________

6.Are there any major dependants listed on page 1 other than the widow, e.g. major child, mother, brother etc YES ฀ NO ฀. If YES, please arrange for each to complete Annexure ‘E’ / ‘F’ and provide details of their names and residential addresses._____________________________________________________________________________

______________________________________________________________________________________________

Is there a Last Will and Testament? YES ฀ NO ฀. If YES, supply a copy.

Has the deceased's Estate been registered? YES ฀ NO ฀. If YES, supply name and address of Executor.

_____________________________________________________________________________________

_____________________________________________________________________________________

7.Is the Estate solvent? YES ฀ NO ฀

8.If member died as a result of illness / injury and was ill or unemployed at date of death, please supply copies of all medical certificates on hand.

9.Did the deceased belong to a Trade Union? YES ฀ NO ฀. Which one? ____________________________

10.If widow has remarried, please supply a copy of her current marriage certificate.

11.If there is any further information that may assist the Trustees in making a fair distribution of the benefit please provide the details on Annexure ‘G’.

____________________________	___________
SIGNATURE OF APPLICANT	DATE

NOTE WELL :

(i)ALL AFFIDAVITS TO BE SIGNED BY A COMMISSIONER OF OATHS & BEAR HIS RUBBER STAMP

(ii)NO ALTERATIONS OR TIPPEX ON ANY OF THE DOCUMENTS WILL BE PERMITTED

(iii)

IF NECESSARY COPIES MAY BE MADE OF ANY OF THESE FORMS

5.