APPLICATION FOR FUNERAL GRANT
(TO BE COMPLETED BY AUTHORIZED MEMBER OF THE FAMILY OF THE DECEASED PERSON)
WARNING:
Any person who for the purpose of obtaining any benefit for himself or some other persons makes any false
statement or representation or produce or cause to be produced or furnished any document or information which he
knows to be false in material particular, is guilty of any offence under the Local Authorities Pensions Fund Act (No. 9
of 2006).
Use CAPITAL LETTERS
A.
PARTICULARS OF A DECEASED MEMBER
1.
Surname___________________________________________________________________________
2.
Other______________________________________________________________________________
3.
Previous/Maiden Name________________________________________________________________
4.
Father’s Name______________________________________________________________________
5.
Mother’s Name ______________________________________________________________________
6.
Death Certificate Number______________________________________________________________
7.
Date of Death_______________________________________________________________________
8.
LAPF Registration Number ____________________________________________________________
9.
Name of last employer ________________________________________________________________
10. Number of the employer ______________________________________________________________
B. EMPLOYERS DETAILS
11. I certify that the particulars of the employee as recorded above are correct and true and in
accordance to
his/her records.
12. Name and address of Employer ________________________________________________________
13. Employer’s Representative Name ______________________ Designation ______________________
Signature and rubber stamp _____________________________________ Date __________________
C. CLAIMANTS PARTICULARS
1. Surname ____________________________________________________________________________
2. Other Names ________________________________________________________________________
3. Date of Birth ________________________________________________________________________
4. Place of Birth ________________________________________________________________________
5. LAPF Registration No. (if any) ___________________________________________________________
6. Address ____________________________________________________________________________
7. Relationship with a deceased person _____________________________________________________
D. DOCUMENTS TO SUPPORT CLAIM
I attach the Following document to support my claim:
E.

Dully filled application form for funeral grant (LAPF/BEN.4);

LAPF Membership Card if available;

Certified Copy of Burial permit or Death Certificate;

Certified copy of Minutes of the meeting of relatives appointing the applicant;

One Picture Passport Size; and

Certified copy of Bank Identity Card.
PAYMENT INSTRUCTION:
Please pay benefit to ____________________ Bank _________________ Branch _____________
Account No. _______________________________ Town _________________________________
To be collected at LAPF Office _______________________________________________________
________________________________________________________________________________
F.
DECLARATION OF APPLICANT
I declare that the statements given in this form are true to the best of my knowledge and belief.
……………………………
Right Hand
Signature of Claimant
Thumb Print
Date ………………………
G.
CERTIFICATION BY ZONAL MANAGER
This is to certify that ______________________________________________________________
Has submitted benefit claims with all the supporting documents and has been paid Tsh.._______________
as Funeral grants (see payment advice attached.
Name: __________________________________________ Signature: ____________________
Office Stamp: _____________________________________
Date: _______________________