a Fy a Hit | UNCLAIMED CLAIM FORM momen c um retirement administrators a MEMBER PERSONAL DETAILS aa Employee No Title [_] Adv Or Capt Prof Ms mrs TF] Mr Miss Me ‘Sumame First Name Identity NUMBEr fate OF Birth (GarmInIyyyy) Passport Number Country of Origin income Tax Number Residential Address Postal Code Postal Address le Postel Gode HE Contact No \ Ema ; LY) DIVORCE DECREE/COURT ORDER } Do you have any Divoree Decree/Court Orders that the fund should be notified about? | (iF Yes, complete details below) [_]¥es |_{No } | The Divorce Amendment Act 7 of 1989 defines pension interest as an amount equal to the withdrawal benefit which would have become payable in terms of the rules of the fund ifthe member had withdrawn on the date of the Teer should you be dored please prove dete of any caiman thal the FUND shouldbe noifed about. (Details of Ex Spouse fe ) | Title] Adv Or Capt Prof Ms Mrs Me Miss Me | First Name! | ‘Sumame | Contack Adaress Postal Code Contact No t T Page 1 of 2 , | ‘Completed documents to be forwarded to: : | Postnet Sule No-388, Prive Bag X30500, HOUGHTON, 2041ao Pe a aa ( BENEFIT OPTION | Benefits are paid in terms of the rules of the specific Fund. | ‘1 Full benefit to be paid as a cash lumpsum. (Complete your bank details) '2[_] Full transfer of benefit to an Approved Fund 3[__] Pertal transfer of benefit to an Approved Fund % Percentage to be transferred, Number of annuities purchased. (Max 4) If option 2 or 3 is selected please ensure a REGISTERED INSURER TRANSFER DETAIL form is completed per annuity purchases. Name of the Account Holder MEMBER BANK DETAES Bank Name Branch Code “Account Number ‘Recount Typa [Zisevege —[]traneission Cheque DECLARATION BY MEMBER hereby confirm that: the details provided herein are true and correct in every way; | understand the options available to ‘me with regard to the payment of my benefits, including the tax implications and that | am making an informed choice; in the event of any loss suffered as a result of any details provided herein being incorrect, neither the fund nor ‘Metropolitan Retirement Administrators can be held liable for such losses. Sumame ; ct y t t First name | a Iaentity Number f T ; Date 7 7[2[e EE Momnees Sloane! ae AGENCY/AGENT DETAILS [ acency copes: Agency Code | 001 GREYSTONE TRACING: | 002 THE DATAFACTORY | 003 1eTS TRACING senvices | | | Contact No L Agents Signatre : a roy T Page 2 of 2 a Bo