MGF form nr 12
August 2012
MUNICIPAL GRATUITY FUND ADMINISTERED BY
Private Bag X14, Highveld Park, 0169
APPLICATION FOR IMMEDIATE NEEDS DEATH BENEFIT
IN THE EVENT OF THE DEATH OF A MEMBER ONLY
CHECKLIST OF DOCUMENTS:
To expedite the payment of the immediate needs death benefit, duly certified copies (containing the full
names and street address of the Commissioner of Oaths) of the under mentioned documents must
accompany your application form:
1
Applicant’s identity document
2
Identity document and death certificate of deceased member
3
Witness’s identity document (witness should be deceased’s family)
4
Bank statement with a stamp from the bank
The application form and listed documents to be send to:
Mgf.death@coriscapital.com or
Fax: 012 683-3994
CONTACT DETAILS OF HUMAN RESOURCES OFFICIAL
Municipality:
Name of official:
Position held:
Telephone number:
E-mail address:
SIGNATURE OF HUMAN RECOURSES OFFICIAL:
__________________________
PARTICULARS OF DECEASED
Pension number:
First names and surname:
Identity number:
Date of death:
PARTICULARS OF APPLICANT
First names and surname:
Relationship with deceased:
Spouse
Child
Guardian
Parent
Other: (Specify and attach proof e.g. Life partner etc)
Nature of dependency
Monetary value of dependency
R
Identity number:
1
Brother/Sister
Girlfriend
Address:
Residential Address
Postal Address
Please provide residential
and postal addresses.
Name of village:
Telephone number:
Fax number:
Cell phone number:
Home language:
Email address:
PAYMENT OF BENEFITS
Name of account
holder:
Identity number:
Bank:
Branch:
Branch code:
Account number:
THE ABOVEMENTIONED PARTICULARS ARE CORRECT IN EVERY RESPECT
I THE ABOVEMENTIONED DECLARE UNDER OATH THAT THE ABOVE
INFORMATION IS TRUE AND CORRECT IN EVERY RESPECT.
SIGNATURE OR RIGHT-HAND THUMB PRINT OF APPLICANT
________________________________________
DECLARATION BY WITNESS (DECEASED’S FAMILY MEMBER)
I, (full name)
Identity number
declare herewith under oath that, to the
best of my knowledge, the applicant _________________________ is the responsible person to handle all
financial
affairs with regards to the immediate needs after the death of the late:
___________________________________________
My address
My telephone number
Please note that the witness must be a member of the deceased’s family
SIGNATURE OR RIGHT-HAND THUMB PRINT OF WITNESS
________________________________________
2
Signed and sworn to before me at
on this
day of
201_ by the above who acknowledges and declares that the
contents hereof are to the best of his/her knowledge correct, that he/she has no objection in
taking the oath and that he/she considers the oath to be binding on his/her conscience.
* To be signed in the presence of a Clergyman, Justice of the Peace or Commissioner of Oaths.
PLEASE COMPLETE IN FULL
TO BE COMPLETED BY CLERGYMAN, JUSTICE OF THE PEACE/COMMISSIONER OF OATHS
Signature:
Full name and surname:
Position held:
Street address:
Area:
Force number:
This claim will be paid within 48 hours after receipt of this application form duly completed and all
documents as stipulated on page one of this document. Please note that payment can only be made
to a beneficiary in terms of the Pension Funds Act. Payment will not be made if the claim is not
submitted within 1 month from date of death, but the amount will then be distributed together with the
balance of the death benefit in accordance with section 37C of the Pension Funds Act of 1956.
3