corporate

FundsAtWork Umbrella Funds

Withdrawal form (resignation, dismissal, end of contract, retrenchment,
employer’s termination of participation in the Fund (Not Section 14), other)
Member number
Please note that MEB003 must be completed for retirement, ill-health or retrenchment.
Please complete this form using the fields provided. Use the tab key to move from one field to the next.

Please attach the following documents:

• A copy of ID / Passport (If you have an identity card, please submit a copy of the front and back of the card).
Note:
SARS does not allow cancellation of a tax directive once it is received. Please consider your choice carefully before this form is sent to Momentum
for processing.

Section 1: Employer and fund details

Name of fund FundsAtWork Umbrella Pension Fund FundsAtWork Umbrella Provident Fund

Name of employer

Section 2: Member details

Employee number 1387

Title Mr Initial/s NB

First name

Surname
D D M M Y Y Y Y
Date of birth - -

RSA ID Yes No ID / Passport no

Passport country of origin

Residential address

Postal code

Postal address

Postal code

Telephone - work Fax

Telephone - home Cellphone number

Email address

Alternative email address

Tax Office Tax number

1 001 0622
MEB
Section 3: Withdrawal details (to be completed by the employer)

Reason for withdrawal Resignation ✔ Dismissal End of contract Retrenchment

Reason for withdrawal Employer’s termination of participation in the Fund(Not Section 14)

Reason for withdrawal Other (Please specify)

D D M M Y Y
Month of last contribution deducted from the member - - 2 0
D D M M Y Y
Effective date of withdrawal as indicated by the member - - 2 0

If last contribution date differs from withdrawal date, please provide reason:

If the member belongs to the Pension and Provident Fund please complete both tables
Pension Fund Provident Fund

Amount of last contribution - Member R R

Amount of last contribution - Employer R R

Member’s last contributions

• Contributions are payable up to the date of exit. If the member is leaving halfway through the month, the contributions will be a pro-rata amount
based on the number of calendar days to the date of exit. You will be able to increase the amount expected to match the total amount on the payroll
but not decrease the amount.
• Example: If a member leaves on 20 June, a full month’s contribution of R1 000 + 30 calendar days in the month X 20 = R666.67.
• We have assumed that no additional voluntary contributions (AVCs) will be paid for the member in their last month. If this is not correct, please add
the AVCs in the space provided.
Additional voluntary contributions: R

Section 4: Indebtedness to employer (to be completed by the employer)

In terms of Section 37D of the Pension Funds Act, a member’s benefit may be reduced -
• if the member has caused damages to the employer as a result of fraud, theft, dishonesty or misconduct. The member must have admitted to the
liability in writing or there must have been a compensatory court order that has been obtained ordering the member to repay the damages to the
employer. The employer must inform the Fund in writing of a potential claim against an employee within 30 days after the employee’s service was
terminated. Please provide proof of the court order obtained or the written admission of liability by the member.
• if the employer granted a loan to the member for purposes of a housing loan as mentioned in Section 19(5)(a) of the Pension Funds Act. Please
provide proof of such loan agreement.
Damages caused to the employer Yes No

Amount to be deducted in favour of the employer for damages R

Housing loan provided to the member by the employer Yes No

Amount to be deducted for the outstanding Housing loan amount R

The recovery of personal indebtedness to the employer (such as personal loans, cell phone costs, etc) is not permitted

Section 5: Declaration by employer (authorised signatory)

I, (full names)

certify that all particulars furnished in this form and accompanying documentation are true and correct. In particular, I confirm that the reason for
withdrawal as indicated in Section 3 is as stated, and that the withdrawal is not an attempt to circumvent the liquidation process. I undertake to bear any
expenses incurred or damages caused as a result of incorrect information.
Signed at

Designation

D D M M Y Y Y Y
- -
Signature on behalf of employer Date

2
Section 6: Withdrawal details and options (to be completed by the member)
If you belong to the FundsAtWork Umbrella Pension Fund, complete the Pension Fund section.
If you belong to the FundsAtWork Umbrella Provident Fund, complete the Provident Fund section.
If you belong to both, complete both the Pension Fund and Provident Fund sections.

Lump sum withdrawals are subject to income tax.

Pension Fund
keep the whole withdrawal benefit in the FundsAtWork Umbrella Pension Fund.
transfer the whole withdrawal benefit to the Momentum Corporate Pension Preservation Fund (not necessary to complete section 6b and 6c);
transfer the whole withdrawal benefit to another approved pension fund, approved pension preservation fund or approved retirement annuity fund
(complete section 6c)
take a portion of the withdrawal benefit as a lump sum and transfer the balance to the Momentum Corporate Pension Preservation Fund
(complete section 6b);
Indicate the rand amount / percentage you want to withdraw as a lump sum R or %
take a portion of the withdrawal benefit as a lump sum and transfer the balance to another approved pension fund, approved pension
preservation fund or approved retirement annuity fund (complete section 6b and 6c);
Indicate the rand amount / percentage you want to withdraw as a lump sum R or %
transfer a portion of the withdrawal benefit to an approved retirement annuity fund and the balance to an approved pension preservation fund
(complete section 6c);
Indicate the percentage you want to transfer to the approved annuity fund % approved preservation fund %
take the whole withdrawal benefit as a lump sum (complete section 6b).

Provident Fund
keep the whole withdrawal benefit in the FundsAtWork Umbrella Provident Fund.
transfer the whole withdrawal benefit to the Momentum Corporate Provident Preservation Fund (not necessary to complete 6b and 6c);
transfer the whole withdrawal benefit to another approved pension fund, approved provident fund, approved pension preservation, approved
provident preservation or approved retirement annuity fund (complete section 6c);
take a portion of the withdrawal benefit as a lump sum and transfer the balance to the Momentum Corporate Provident Preservation Fund
(complete section 6b);
Indicate the rand amount / percentage you want to withdraw as a lump sum R or %
take a portion of the withdrawal benefit as a lump sum and transfer the balance to another approved provident fund, approved provident preservation
fund or approved retirement annuity fund (complete section 6b and 6c);
Indicate the rand amount / percentage you want to withdraw as a lump sum R or %
transfer a portion of the withdrawal benefit to an approved retirement annuity fund and the balance to an approved preservation fund
(complete section 6c);
Indicate the percentage you want to transfer to the approved annuity fund % approved preservation fund %
Split the withdrawal benefit between:
• approved pension fund R or %

• approved provident fund R or %

• approved pension preservation fund R or %

• approved provident preservation fund R or %

• approved retirement annuity fund R or %

✔ take the whole withdrawal benefit as a lump sum (complete section 6b).

3
Section 6a: Retrenchment Options (to be completed by member)
You are entitled to a retrenchment benefit when you lose your job or your job is terminated because:
• Your employer stopped carrying on the trade in which you were employed or appointed, or
• You became redundant due to your employer reducing staff.

If you take your retrenchment benefit as a lump sum, it will be taxed on the retirement lump sum tax table, subject to the cumulative value of any
previous retirement fund withdrawals that you made.

If you transfer it to another fund, the transfer itself will not be taxed, and the type of benefit you then take in that fund will determine which tax table will
apply. If you for instance take a withdrawal benefit from that fund, your benefit will be taxed on the withdrawal lump sum tax table, and not the retirement
lump sum tax table.

Retrenchment Options Pension Fund

keep the whole withdrawal benefit in the FundsAtWork Pension Fund.
Transfer the whole benefit to the Momentum Corporate Pension Preservation Fund or the Momentum Retirement Annuity Fund

Transfer the whole benefit to another approved pension preservation fund, approved pension fund or approved retirement annuity fund
Take a portion of the benefit as a lump sum and transfer the balance to the Momentum Corporate Pension Preservation Fund or the Momentum
Retirement Annuity Fund
Indicate the rand amount / percentage you want to withdraw as a lump sum R or %
Take a portion of the benefit as a lump sum and transfer the balance to another approved pension preservation fund, approved pension fund or
approved retirement annuity fund (complete sections 6b and 6c)
Indicate the rand amount / percentage you want to withdraw as a lump sum R or %
Take the whole benefit in cash (complete section 6b)

Retrenchment Options Provident Fund

Keep the whole benefit in the FundsAtWork Provident Fund
Transfer the whole benefit to the Momentum Corporate Pension Preservation Fund, Momentum Corporate Provident Preservation Fund or the
Momentum Retirement Annuity Fund
Transfer the whole benefit to another approved pension preservation fund, approved provident preservation fund, approved pension fund,
approved provident fund or approved retirement annuity fund
Take a portion of the benefit as a lump sum and transfer the balance to the Momentum Corporate Pension Preservation Fund, Momentum
Corporate Provident Preservation Fund or the Momentum Retirement Annuity Fund (complete section 6c)
Indicate the rand amount / percentage you want to withdraw as a lump sum R or %
Take a portion of the benefit as a lump sum and transfer the balance to another approved pension preservation fund, approved pension fund,
approved provident preservation fund, approved provident fund or approved retirement annuity fund. (sections 6b and 6c);
Indicate the rand amount / percentage you want to withdraw as a lump sum R or %
Take the whole benefit in cash (complete section 6b)

Section 6b: Existing bank account details (if cash was selected)

Name of account holder (member)

Account number

Name of bank/building society:

Branch name Branch code 250655

Account type Current/Cheque Savings Transmission

Digitally signed by
Nkosi
Date: 2022.09.19
16:43:45 +02'00' D D M M Y Y Y Y
1 9 - 0 9 - 2 0 2 2
Member’s signature Date

4
Section 6c: Transfer details (if transfer was selected)
Note:
• While this claim is being processed, the benefit will be placed in Momentum FundsAtWork’s bank account in order to eliminate the possibility of the
benefit being reduced because of volatile market conditions.
1. Name of receiving fund

Percentage to be transferred %
Financial adviser’s name

Telephone work - (code number)

Email address

2. Name of receiving fund

Percentage to be transferred %
Financial adviser’s name

Telephone work - (code number)

Email address

Section 7: Disinvestment effective date (to be completed by the member)

Momentum FundsAtWork will start the disinvestment process of your retirement savings account within 7 days of receiving this withdrawal notification.
If you want your retirement savings account to stay invested until the effective withdrawal date, please tick the below block.

Yes, my retirement savings account should stay invested until the day I leave employment.

The 7 day period is specifically for disinvesting your benefit. Only once the date of accrual is determined in terms of the Rules of the Fund will the actual
payment process commence.

Section 8: Deductions (to be completed by the member)

The following amounts can be deducted from my retirement savings account at disinvestment.
• Home loans for which the Fund/s is / are the guarantor.
• Exceptions permitted in terms of section 37A of the Pension Funds Act in respect of maintenance payments or divorce orders endorsed against the
Fund, entitling the non-member spouse to a portion of the member benefit.

Maintenance order Yes No If yes, please provide maintenance order.

Divorce order Yes No If yes, please provide a copy of the divorce order and complete the divorce order form.

5
Section 9: Declaration by member

I, Nkosikhona B Sibiya (full names)

declare that:
• all particulars furnished in this form are true and correct;
• payment by electronic transfer shall constitute full and final settlement discharging Momentum FundsAtWork of its liability in terms of the Rules of
the Fund;
• the benefit payment options available to me, as well as the tax implications thereof, have been explained to me in full; and
• after seeking the relevant financial advice, I confirm that the choices indicated here are my final instructions and I acknowledge that I am aware that
the benefit paid will be subject to the Fund Rules and relevant legislation.

I agree that Momentum Corporate may process all information that I provide on this form. I understand that the information will be processed in
accordance with the Protection of Personal Information Act, 2013 and Momentum Corporate’s strict policies on protecting the confidentiality of my
personal information.

I agree that Momentum Corporate may use my personal information to provide and administer retirement fund investment and insurance products and
share my personal information with Momentum Corporate’s partners and contracted service providers, who are legally bound to protect the information.

Click here to read the full Privacy Notice.

Digitally signed by
Nkosi Durban
Date: 2022.09.19 Signed at
16:46:45 +02'00' 1D 9D - 0M 9M - 2Y 0Y 2Y 2Y
Member’s signature Date

Completed form together with supporting documents to be faxed to 012 675 3970 or emailed to momentumcorporateclient@momentum.co.za.

Important notice: Insurance conversion option

If your employer elected the conversion option and if you are under the age of 55, you may take up a similar individual policy with Momentum Myriad
at a competitive price for a sum assured less than or equal to the amount of cover you enjoyed under the Umbrella Fund, with no underwriting, except
for a smoker’s test.

You have 90 days from leaving the Umbrella Fund to take up the individual policy from Myriad. If you die or become disabled after leaving the Umbrella
Fund, the insurance benefits from the Umbrella Fund will only cover you for 30 days after leaving the Fund.

In addition, if you transfer from the Umbrella Funds to the Preservation Funds and take out a Myriad policy, you will continue with the Family Protector
education BASE benefit and health premium waiver BASE benefit free of charge. If you transfer from the Umbrella Funds to the Preservation Funds and
only take out retirement benefits without a Myriad policy, only the funeral BASE benefit under the Family Protector will apply, free of charge.

When you sign this form by inserting a digital signature it confirms that the information provided is true and correct.

Options to sign the form:

1. Print out the form, sign and scan it and send it back via email to momentumcorporateclient@momentum.co.za or fax it to +27 (0)12 675 3970.
2. Place your scanned signature in the signature block.
• Store your scanned signature in a safe place on your computer.
• Select the ‘comments’ tab from your menu in Adobe.
• Select the ‘add stamp’ icon.
• Select custom stamps.
• Create custom stamps.
• You can now browse and upload your signature to save it as a custom stamp
under ‘sign here’ in Adobe.
• You can now go back to your ‘stamps’ icon and select ‘sign here’ and select
your saved signature.
• Place it in the document and save the document.

When you want to print the form to complete by hand you can
turn off the field highlights by selecting the “highlight existing
fields” on the top right hand corner of your screen.

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Momentum Metropolitan Life Limited

268 West Avenue Centurion 0157 PO Box 7400 Centurion 0046 South Africa
The Marc, 129 Rivonia Rd, Sandown, Sandton 2196, PO Box, Sandton, South Africa Tel +0860 65 75 85 Fax +27 (0)12 675 3970
Parc du Cap 4, Mispel Road, Bellville, Cape Town 7530, PO Box 2212, Bellville 7535, South Africa Tel +27 (0)21 940 5911 Fax +27 (0)21 940 4320
momentumcorporateclient@momentum.co.za www.momentum.co.za/momentum/business Momentum Corporate is a part of Momentum Metropolitan Life Limited
(registration number 1904/002186/06), a licensed life insurer, authorised financial services and registered credit provider.