Metal Industries Provident Fund: Application for Death Benefits

Tick the relevant fund: Metal Industries Provident Fund or Engineering Industries Pension Fund.

Place a cross in the block which applies to the Marital Status of Deceased: Married, Single, Widowed or Divorced.

If married, or divorced, Marriage or Customary Union Certificate or Divorce Order must be attached. These documents must be certified as true copies of the originals. If Customary Marriage Certificate is unavailable, or a Customary Marriage/Live-in Relationship existed, complete Annexures B.

Enter FIRST NAMES, SURNAME and the Deceased's Identity number or Passport number (If not RSA resident).

Enter the Date of Death. A certified copy of the Death Certificate must be attached.

Enter the Cause of death, Notice of death or Police Report for Unnatural Causes.

Enter the Income Tax Reference No.

If this form is completed with the assistance of the Employer (HR/Wages Department), insert contact details: NAME, TELEPHONE NUMBER, FAX and E-MAIL ADDRESS.

Enter the Applicants Details: Full Names, Identity Number, Unit No, Street no and name, Complex, Suburb/District, City / Town, Country, Postal Code, Cell no, Tel no (h) (w) and Email.

List ALL dependants, including minor children. Major dependants, i.e. children over 18, parents and siblings etc., are to complete a separate Application Form & Bank Mandate.

Enter Name (in full), Address and post code, Age, Relationship to deceased and Tel no.

Birth Certificates/Identity Documents of each of the dependants listed must be attached. Temporary Identity documents are not acceptable.

List the nominees of the deceased and supply evidence of nomination form signed by deceased.

State your relationship to the deceased after: That the deceased was my. All the information given on this application form is true. No alterations or tippex on any of the documents will be permitted.

Enter the Surname of dependant, Maiden name, First name and Identity Number (Identity Document to be produced).

The details of the dependant's account are to be verified by a Bank official as correct and active/current.

Enter the Name of Bank, Address of Bank, Postal Code, Name of Branch, Branch Code (To be supplied by Bank), Account Number and Type of Account.

The applicant's identity document matches or does not match the ID copy held at the bank. Attach a copy of the applicant's bank statement (not older than 3 months).

The account holder signs. Thumbprint if applicant cannot sign.

Enter the Full names of bank official, the Signature of bank official, the Date and the Stamp of bank.

No alterations or tippex will be accepted.

Enter the deceased's full name and 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.

Was the deceased previously married? If YES, 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.

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

Did the deceased have any other children (before marriage)? If YES, supply details of the children's names, residential addresses and birth certificates, and the name and residential address of children's parents / guardians and guardian's relationship to deceased.

Was the deceased required to pay any child maintenance? If YES, supply a certified copy of the Maintenance / Divorce Order.

Are any of the deceased's minor children being cared for by someone other than their mother? If YES, arrange for guardian to complete Annexure C where necessary and provide details of their names and residential addresses.

Are there any major (Over 18 years old) dependants listed on page 1 other than the widow? If YES, arrange for each to complete Annexure D and provide details of their names and residential addresses.

Is there a Last Will and Testament? If YES, supply a copy.

Has the deceased's Estate been registered? If YES, supply name and address of Executor.

Is the deceased's Estate solvent? Are there funds available? Has all of the deceased's debts been settled?

Did the deceased belong to a Trade Union?

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 E.

Enter the Signature of applicant and the Date.

State name and address of employer.

This is to certify that the particulars are a true record of the employment with this Company of: Employee name (in full), Employee's Tax No, Identity No, Co No, Occupation, Date of Engagement, Date of Discharge from Company Records, Actual period of employment as contributor to MIBFA Fund (From, to) and Period of employment on Company's Pension/Provident Fund (From, to).

Form 'D' is 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.

To be completed if there was a mutual agreement between the families and if the customary marriage/ Live-in Relationship was concluded.

3. If you are not the child/children's mother, do you know the whereabouts of the child/children's mother/s? 3.1 If YES, kindly provide names, addresses and contact numbers of the whereabouts of the parent/s and the reason why they are not caring for their child/children.

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.

Annexure D is the affidavit by a major dependant (Daughter, son, mother, father, sibling etc.).

Application for Death Benefits: application is made for benefits under the Rules of the Fund in respect of a death. In the absence of any dependants/nominees the benefit will be paid to the Estate.

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.

The services offered by the Metal Industries Benefit Funds Administrators (MIBFA) are free of charge, and MIBFA does not send out officials to personally consult with dependents at their home or place of work regarding their claim, unless prior arrangements have been made.