A PPLIC A TIO N FO R D EA T H C LA IM Fund
Region
Fund Number
Council Number
For office use only Final contributions
WKS@R From
To
Dated
WKS@R From
To
Dated
Was contributions paid to date of Death
YES
NO
If not please advise reasons:
Additional information: INFORMATION OF DECEASED – to be completed by the EMPLOYER Deceased’s Surname: Full Names: Identity Number:
Date of birth: A copy MUST BE attached to the application
Death date:
Deceased’s income tax no: Copy of death certificate to be attached
LAST SALARY:/WAGES: R
per week/ per month
Employer Name: Employed:
FROM
TO
If applicable – dates member was absent from work immediately prior to death Reason for absence: FROM:
TO
PREVIOUS EMPLOYMENT HISTORY Employed from
to ___________________________Company
Employed from
to ___________________________Company
I the undersigned hereby state that ALL PROVIDENT CONTRIBUTIONS for the above mentioned member will be paid to the fund up to the date of Death
EMPLOYER’S SIGNATURE:
DATE:
1
NOTE: EACH CLAIMANT’S MUST COMPLETE A SEPARATE FORM D/B1 AND BANK FORM
ADDITIONAL DOCUMENTATION REQUIRED I, the undersigned, herby certify that the given information is correct in all aspects. I hereby authorize the fund to deduct any benefits due to the late member, an amount which equates to the prescribed MIMED Contributions in respect of the period during which The late received benefits from MIMED, subsequent to the termination of employment in the Motor Industry, and the consequential of the membership of MIMED.
BENEFICIARY’S SIGNATURE: ____________________________________DATE:
P lease note the following docum ent’s are required with the application: Copy of the late m em ber’s ID docum ent
D B 1 for each Claim ant
M edical report’s – if applicable
ID’s of all Claim ant’s
Death Certificate
Birth Certificate’s of All m inor children
Form A & D – to be com pleted by EM PL O Y E R
Sworn Statem ent’s
M arriage Certificate
Beneficiary form
/ Sworn Statem ent
If Divorce, divorce order
Affidavit - W ho cares for m inor children
PLEASE SEND COMPLETED DOCUMENTATION TO ONE OF THE FOLLOWING REGIONAL OFFICES: REGION MIBCO Eastern Cape PO BOX 7270 PORT ELIZABETH 6055 MIBCO Natal PO BOX 17263 CONGELLA 4013 MIBCO Free State OFS PO BOX 910 BLOEMFONTEIN 9300 MIBCO SSC PO BOX 2578 RANDBURG 2125 MIBCO Western Province PO BOX 17 BELLVILLE 7535
CONTACT NUMBER [041] 3640250
[031] 2055465
[051] 4094000
[011] 3697500
[021] 9486400/05
2
Form A&D
INCOME TAX
Request for a tax deduction directive Pension and Provident funds Year of assessment ended on:
C C Y Y
M M
D D
For official use Application number
Income tax reference number
Particulars of member Surname First names Date of birth
C
C
Y
M
Y
D
M
Identity number
D
Specify other identification
Other identification
If the taxpayer/member is not registered for Income tax, select one of the following reasons: Unemployed
SITE Annual income
Other, specify
R
Employee number
Residential address
Postal code Postal address
Postal code
Particulars of fund Name of fund Contact person Telephone number Fund approval number
C
O
D
N
E
U
1 8 2 0 4
M
B
E
R
Fund PAYE reference number
Membership number
Type of fund:
7 Provident
Pension
Postal address
Postal code Indicate whether this fund is 01 A public sector fund
02 An approved fund
99 Other, specify
Particulars of gross lump sum due Reason for directive:
Date of accrual
C
Death
Retirement
Unclaimed benefit
Retirement due to ill-heath
Provident fund deemed retirement
Surplus apportionment
C
Y
Y
M
M
D
D
Date on which the member became a member of the fund
Gross amount of lump sum payment
C
C
Y
Y
M
M
D
(Including the amount deemed to be accrual in respect of par 2B of the Second Schedule)
R
Gross amount of total benefit
R
Amount attributed to a non-member’s spouse in respect of divorce order
R
In case of a provident fund, total contributions by member to the fund (excluding interest and profit)
R
,
In the case of a pension fund, where a member’s contribution to the fund have exceeded such amounts as ranked for deduction against his income in terms of paragraph (k) of Section 11 of the Income tax Act, state total amount of excess during membership.
R
,
1-3
, , ,
D
Particulars of gross lump sum due (Continue) Was a period consisting of a number of completed years used to determine the quantum of the benefit in terms of a formula prescribed in terms of the rules of the fund?
YES
NO
IF ‘YES’ provide the period of employment taken into account in terms of the rules of the fund: Date from
C
C
Y
M
Y
D
M
D
Date to C
C
Y
Y
M
M
D
D
=
Completed years
M
M
D
D
=
Completed years
IF ‘NO’ provide the period of membership of this fund during which contributions were made: Date from
C
C
Y
M
Y
D
M
D
Date to C
C
Y
Y
Did the fund purchase an annuity?
YES
NO
YES
NO
R
IF ‘YES’ , state the amount utilised to purchase the annuity Name of the registered long-term insurer where the annuity was purchased:
Annuity policy number If ‘NO’, is the fund paying the annuity? R
If ‘YES’, the amount remaining in the fund to fund the annuity
Particulars of salary earned Highest average salary earned by the taxpayer during any 5 consecutive year in the service of the employer during his membership of the fund: Start date
End date
Salary
C
C
Y
Y
M
M
D
D
to
C
C
Y
Y
M
M
D
D
R
C
C
Y
Y
M
M
D
D
to
C
C
Y
Y
M
M
D
D
R
C
C
Y
Y
M
M
D
D
to
C
C
Y
Y
M
M
D
D
R
C
C
Y
Y
M
M
D
D
to
C
C
Y
Y
M
M
D
D
R
C
C
Y
Y
M
M
D
D
to
C
C
Y
Y
M
M
D
D
R Total
R
Average for 5 years or lesser period if employee employed for lesser period.
R
On death: The members’ salary during 12 months immediately preceding death.
R
Note: Salary includes any amount received or receivable annually under a contract of service including cost of living allowances, commission, shares of profits, etc., but not occasional bonuses or fees which were dependant on the whim of Directors or employer. Particulars of employer Name of fund PAYE reference number
7
Contact person Telephone number
C
O
D
E
N
U
M
B
E
R
Postal address
Postal code Physical address
Postal code
Declaration Certified to be true and correct to the best of my knowledge.
C Signature of administrator
C
Y
Y
M Date
2-3
M
D
D
Definitions Other identification:
Passport number, work permits number, etc.
Annual Income:
Must reflect all income for a full year for e.g. Salary, remuneration, earnings, emolument, wages, bonus, fees, gratuities, commission, pension, overtime payments, royalties, stipend, allowances and benefits, interest, annuities, share of profits, rental income, compensation, honorarium.
Employee number:
A number allocated by the employer to the employee.
Fund Approval Number: The number allocated to the Fund by SARS, which consists of 18/20/4 plus six other numbers. The period taken into account in calculating the lump sum benefit: Date from and Date to. If there was a break in service, the period should be deducted from the “Date from” to establish the completed years. If a member of a Public Sector Fund and service years was purchased or approved after 1 March 1998, the period must be added to the ‘Date to’ (the period will then end in the future).
3-3
FUND
REGION
FUND NUMBER
COUNCIL NUMBER
R E Q U E ST F O R A D IR E C T O N LIN E PA Y M E N T O F B E N E F ITS I request you to pay my benefit payable to me, to the credit of my account at the under mentioned Bank Ek versoek u om my voordeel op krediet van my rekening by die ondergenoemde Bank in te betaal.
PLEASE NOTE ACCOUNT MUST BE IN YOUR NAME (MEMBER) Initials and S urn am e: V oorletters en V an: Postal Address: Posadres: Postal Code:
ID Number / ID nommer: Telephone number:
Work / Werk:
Telefoon nommer:
Cell number:
Home / Huis:
Signature: Handtekening:
Date: Datum:
TO BE COMPLETED BY THE BANK / MOET DEUR U BANK VOLTOOI WORD An account has already been opened at the following Bank Ek het reeds ‘n rekening by die volgende Bank geopen Account holder’s Name: Rekeninghouer se Naam:
Bank
Branch: Tak:
Type of account / Tipe rekening: C H E Q U E / T JE K
S A V IN G S / S PA A R
T R A N S M IS S IO N / T R A N S M IS S IE
Controlling Branch Number / Beheertakkode: Account Number / Rekeningnommer:
INFORMATION VERIFIED BY BANK INLIGTING GEKONTROLEER DEUR BANK. BANK STAMP BANK STEMPEL
Signature of Bank Official Handtekening van Bankamptenaar
DB1
CLAIM FO R DEA TH BENEFITS IN R ESPECT O F THE LATE : FULL NAMES OF DEC EASED MEMBER : IDENTITY NO :
FUND NO :
The following questions to be answered fully by person claiming payment of the death benefit. 1.
DECEASED’S RESIDENTIAL ADDRESS AT TIM E OF DEATH :
2.
(i)
OCCUPATION :
(ii)
NAME OF LAST EMPLOYER : POSTAL ADDRESS : CONTAC T PERSON :
3.
(i)
DATE OF DEATH :
(ii)
W HE RE DID MEMBER DIE :
TELEPHONE NO :
CAUSE OF DEATH : (iii)
W AS DECEASED ILL PRIOR TO D EATH, IF SO, FOR HOW LON G :
*
Certified copy of Death Certificate to be attached.
4.
DETAILS OF REPRESENTATIVE / EXECUTOR OF THE ESTATE NAME AND ADDRESS: TELEPHO NE NUMBER :
*
Letter of appointm ent to be attached.
5.
IF APPLICABLE, THE DECEASED’S NOMINATED BENEFICIARY IS :
6.
DETAILS OF DEPENDANTS OF DECEASED
6.1
MARITAL STATUS OF DECEASED MEMBER : Please tick one of the following :
*
Legally Married
Customary (Lobola) marriage
Common -law (living together)
Estranged / Separated
W idow / W idower
Girlfriend / Boyfriend
Divorced
Single
Proof to be attached, i.e. m arriage certificate, divorce order, affidavits.
1
6.2
IF COMM ON -LAW SPOUSE FOR HOW LONG DID YOU SHARE A C OM M ON HOUSEHOLD:
6.3
FULL NAMES OF SPOU SE / PARTNER : ADDRESS :
6.4
CHILDREN BORN FR OM THIS RELATIONSHIP : NAMES
AGE
NAMES
1.
5.
2.
6.
3.
7.
4.
8.
AGE
*
Copies of birth certificates and/or I.D . Docum ents to be attached.
7.
CLAIMANT’S DETAILS :
7.1
NAME :
7.2
RELATIONSHIP TO THE DECEASED :
7.3
IN W HAT CAPACITY ARE YOU CLAIMING THE BENEFIT ?
8.
ARE YOU AW ARE OF ANYONE ELSE W HO MAY BE A POSSIBLE DEPENDANT / BENEFICIARY OF THE DECEASED? PLEASE STATE : (i)
RELATIONSHIP TO THE DECEASED :
(ii)
NAME :
(iii)
CONTAC T TELEPHONE NO. :
9.
W HO PAID FOR THE FUNERAL ?
9.1
NAME :
9.2
RELATIONSHIP TO THE DECEASED :
CLAIMANT’S DECLARATION (CERTIFICATE) IN RESPECT OF DEATH CLAIM : NAME IN FULL : IDENTITY NO. (P lease attach a copy) : POSTAL ADDRESS : TELEPHONE NUMBERS
(HOME) : (
)
AT W ORK : (
)
(CELL) : OCCUPATION :
I HEREBY DECLARE THAT THE ABOVE DETAILS TO THE BEST OF MY KNOW LED GE IS TRUE AND ACCURATE.
SIGNATURE :
NB :
DATE :
BANK ACCOUNT DETA ILS : GET FOR M ON TH E W EBSITE
2
