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.

ANNEXURE ‘E’

AFFIDAVIT BY DECEASED’S MAJOR DEPENDANT/CHILDREN

(For completion by major biological dependant children of the deceased).

I (full names) :					Identity Number:
						(Please attach a copy of Identity Document)
Residential Address :
							Postal Code : ____________
Tel No. (H)					Cell No. ____________________________

do hereby make an oath and say that:

1.	The deceased (full names)				I.D. No:
	was my			(State relationship)

2.That I was dependant on the deceased at date of his death for the following :- (e.g. schooling, food, rent etc). R ______________________ pm

R ______________________ pm R ______________________ pm

	R ______________________ pm
Total	R ______________________ pm

3.At date of death I was employed at _________________________________ (Tel no.) ________________

at a salary/wage of R _____________________ per week/per month.

I know and understand the contents of this affidavit, that the facts herein are to the best of my knowledge true and correct and I have no objection in taking the prescribed oath which I consider to be binding on my conscience.

____________________________

SIGNATURE OF DEPONENT

Signed and sworn before me at (place)_____________________________ on this_______________________ day

of (MONTH) ______________________ (YEAR)

, by the deponent who has acknowledged that he/she knows

and understands the contents of this affidavit.

COMMISSIONER OF OATHS

COMMISSIONER’S STAMP

NOTE : Commissioner of Oaths are available at any Police Station, Post Office, the Office of any Attorney, or at the Fund’s Office or a Tribal Chief or Induna.

* IF NECESSARY COPIES MAY BE MADE OF ANY OF THESE FORMS

9.

ANNEXURE ‘G’

AFFIDAVIT

I, (NAME): _____________________________________________________________________________

ID NO: ___________________________________________________________________________________

(Please attach copy of Identity Document)

Residential Address: _________________________________________________________________________

Tel No: _________________ Cell No. ____________________

do hereby make an oath and say that: the deceased (full names) ______________________________________

Id No: ___________________________

was my _______________________________ (state relationship)

I further state that :

I know and understand the contents of this affidavit, that the facts herein are to the best of my knowledge true and correct and I have no objection in taking the prescribed oath which I consider to be binding on my conscience.

				____________________________
						SIGNATURE OF DEPONENT
Signed and sworn before me at (place)						on this ___________________day
of (MONTH)		(YEAR)			, by the deponent who has acknowledged that he/she knows

and understands the contents of this affidavit.

COMMISSIONER OF OATHS

COMMISSIONER’S STAMP

NOTE : Commissioner of Oaths are available at any Police Station, Post Office, the Office of any Attorney, or at the Fund’s Office or a Tribal Chief or Induna.

* IF NECESSARY COPIES MAY BE MADE OF ANY OF THESE FORMS

11.

DISPOSAL OF LUMP SUM DEATH BENEFITS:

In terms of Section 37 © of the Pension Funds Act, a member’s dependants and persons who are not dependants but who are nominated by the member must be taken into account by the Trustees when they decide in what shares lump sum benefits are to be paid on the death of a member of a registered pension or provident fund.

The Fund shall within 12 months of the death of the member, endeavour to trace all dependants/nominees and shall pay benefits to same or all of such dependants/nominees in proportions as may be deemed equitable by the Trustees. In the absence of any dependants/nominees the benefit will be paid to the Estate.

Briefly, the position is as follows:

(a)the following categories of persons will be dependants:

(i)persons for whose maintenance the member is legally liable;

(ii)persons whom the Trustees consider to have been dependant upon the member at the time of his/her death;

(iii)the spouse and children (both minor and major) of the deceased member; and

(iv)persons for whose maintenance the member would have become legally liable if he or she had not died (for example an unborn child);

(b)if there are dependants and no nominees, payment must be made to - or for the benefit of - one, some, or all of those dependants in such proportions as the Trustees shall determine;

(c)if there are no dependants but the member has nominated one or more persons who are not dependants to receive part or all of the benefit, then such nominees only receive payment of benefits after debts in the deceased estate have been paid, if the member’s estate is insolvent;

(d)if there are dependants and the member has nominated one or more persons who are not dependants to receive part or all of the benefit, the Trustees shall determine the proportion which is to be paid to each dependant and the proportion to each nominee (a nil proportion may be allocated);

(e)only if there are no dependants, and then only to the extent that payment is not due to a nominee, shall any balance remaining be paid to the deceased member’s estate, or, where appropriate, the Guardian’s Fund;

(f)Trustees have the right to pay to a trust for the benefit of a minor dependant or minor nominee or to pay the lump sum in the form of instalments over a period of time;

(g)if there are both dependants and nominated beneficiaries, such nominations must have been made on or after 30 June 1989. Nominations made prior to that date are not valid.

(h)lump sums can be paid in the form of instalments over a period of time to major dependants or nominees, if agreed in writing by the dependant or nominee.

NOTES:	(i)	any income tax payable will be deducted before lump sum benefits are allocated to dependants and nominees;
	(ii)	the fact that a person is classified as a dependant or nominee does not mean that the Trustees must award him or her any benefit from the fund;
	(iii)	an institution (e.g. an old-age home) can be chosen as a nominee;
	(iv)	the requirements set out above do not apply to pensions payable to spouses or dependants in terms of specific provisions of the rules: such pensions
		are payable as described in the rules;
	(v)	the requirements set out above do not apply to free-standing Group Life Assurance Funds;
	(vi)	prior to 19 April 1996 major children did not automatically qualify as dependants.
		Aug ’08/mc