Engineering Industries Pension Fund Metal Industries Provident Fund

PLEASE TICK √ RELEVANT FUND

METAL INDUSTRIES HOUSE P.O. BOX 7507

42 ANDERSON STREET JOHANNESBURG, 2000
JOHANNESBURG TEL NO. (011) 870-2000
2001 CALL CENTRE NO 0860102544
Website: http://www.mibfa.co.za
APPLICATION FOR PAYMENT OF BENEFITS ON
RESIGNATION, RETRENCHMENT OR RETIREMENT
NOTE TO EMPLOYER:
If this form is completed with the assistance of the Employer (HR/Wages Department), please insert contact details:
NAME: TELEPHONE NUMBER:
FAX : E-MAIL ADDRESS:

* Surname ____________________________________ First names _________________________________________ Initials _________

* Residential Address: * Postal Address:

Unit No: __________________________ Complex: ________________________________

Street No: _____________________________ P O Box: _____________________________________

Suburb / District: _____________________________ Suburb / District: _________________________________

City / Town: _____________________________ City / Town: _________________________________
Country: ____________________________ Country: _________________________________
Postal Code: ______________________ Postal Code: ____________________
Home Telephone No: ______________________________ Cell No: _____________________________________

Works Telephone No: ______________________________ E-mail Address: _____________________________________

Identity Number
* (Certified copy of Identity document must be attached)
Reference Book Number
Previous Passport/Identity Numbers
(Certified copies must be attached)
Country of origin / issue: _____________________________________
Marital Status – (place cross in block which applies) ……………………..
* (Certified copies of Marriage Certificate or Divorce Order, Annexure must be attached)
MARRIED SINGLE WIDOWED DIVORCED

* Final date of employment in Metal Industries DD MM YY

* Name of current Employer _________________________________________________________________________

* Income Tax Reference No: ……………………..……….
Revenue Office to which last Tax Return rendered ___________________________________________________
OPTION TO TRANSFER TO AN ANNUITY OF YOUR CHOICE YES NO
(MEMBERS WISHING TO TRANSFER THEIR BENEFITS TO AN ANNUITY SHOULD SEEK ADVICE FROM THEIR FINANCIAL ADVISOR / BROKER).

FOR COMPLETION BY MEMBERS OF THE ENGINEERING INDUSTRIES PENSION FUND WHO ARE 55 YEARS AND OLDER:
One-third lump sum plus reduced monthly pension
INDICATE YOUR OPTION OF PENSION: OR
Full monthly pension e
s
ey
LIST ALL DEPENDANTS se
NAME IN FULL ADDRESS AND POSTAL CODE AGE y
RELATIONSHIP
s
e
s

If this space is insufficient please attach an additional list I declare that all the information given on this form is true.
NB. All alterations to be signed in full by member
CONSENT: I agree that the Metal Industries Benefit Funds Administrators (MIBFA) may collect, use, disclose and otherwise process my personal information, as
contained in this application form or as otherwise collected through my participation in either the Engineering Industries Pension Fund or the Metal Industries
Provident Fund, for the specific purpose of processing payment of, and an application for payment of benefits. By completing and signing this application form, I
further agree that MIBFA may take steps to verify specific personal information relating to me and, for this purpose, may obtain my personal information from, or
verify my personal information with, amongst others, previous employers, banking institutions, the South African Revenue Service, and medical professionals.

_____________________________________
Compulsory fields to be completed DATE DD MM YY 1.
* * Signature or mark of applicant
 MANDATE FOR PAYMENT OF BENEFIT TO BANK
NO ALTERATIONS OR TIPPEX WILL BE ACCEPTED

NB: ACCOUNT HOLDERS MUST ATTACH A CURRENT BANK STATEMENT WITH BANK STAMP IMPRINTED THEREON.

* A. APPLICANT’S BANK DETAILS:

(1) Surname of Applicant (Payee)

(2) Maiden Name

(3) First name of Applicant (Payee)

(4) Identity Number

Identity Document to be produced

* B. DETAILS OF ACCOUNT - N.B To be verified by Bank official as correct and active/current

and belonging to the applicant as listed on page 1.

(1) Name of Bank

(2) Address of Bank

Postal Code Poskode

(3) Name of Branch

(4) *Branch Code

* Code at place where account is kept will be supplied by Bank.
(5) Account Number

(6) Type of Account

(7) Date account opened DD MM YY

………………………………………….
FULL NAMES
OF BANK OFFICIAL

…….………………………………….
SIGNATURE OF
ACCOUNT HOLDER
( Must be the same signature
* as the applicant's on page 1)

…………………………......... SIGNATURE OF OFFICIAL

DATE AND STAMP OF BANK

2.
 CERTIFICATE OF SERVICE
(State name and address of employer.
To be imprinted with Firm's rubber stamp.)

Company Ref No: ………………………………….........................

This is to certify that the particulars as mentioned hereunder are a true record of the employment by this Company of:

Employee name (in full): .......................................................................................................................................................................……….

Identity No: ..................................................................................... Works/Company No: ...................................................………………..……

Occupation: ...........................................................................................................................................................................…………..……..…..

Period of employment as contributor to Fund: From ....................................................... to ...............................................................……….

Period of employment on Company's domestic Fund: From .................................................... to ..................................……………………….…

Reason for termination of employment: Please tick √

Retirement Medical Retrenchment /
(55 years and older) Incapacitation Redundancy
Resignation/ Contract Absconded
Dismissal Expired
Death

"Remuneration" at date of termination of employment

WEEKLY PAID EMPLOYEE MONTHLY PAID EMPLOYEE

R..................................... per week R...................................... per month

Breakdown of contributions for final month of employment plus any outstanding leave pay, would be appreciated.
..........................................................................................................................................................................................
OPEN DATE CLOSE DATE SHIFTS WORKED
Shifts worked and contributions paid for the last
three months worked prior to the member’s
date of discharge

It is hereby acknowledged that the Employer will be held

liable for any loss incurred by the Fund in consequence of
a false declaration of Retrenchment/Redundancy.

.......................................................
FOR AND ON BEHALF OF EMPLOYER

DESIGNATION : ………………………………………

NAME: ………………………………………

TELEPHONE NO.: ……………………………………… DATE : ………………………………………

3
.3.
 TO BE COMPLETED BY THE EMPLOYER
IN RESPECT OF A RETIREMENT CLAIM ONLY
(FOR INCOME TAX PURPOSES)

PENSION AND PROVIDENT FUNDS - FORM 'D'

Name of Employer : ______________________________________________________

Address of Employer : ______________________________________________________

______________________________________________________

______________________________________________________

1. Employee's Surname : ______________________________________________________

Employee's First Names : ______________________________________________________

Employee's Identity no. : ______________________________________________________

Employee's Tax no. : ______________________________________________________

2. Highest average salary actually earned by the taxpayer during any five consecutive years in the service
of the employer during his membership of the Fund.

Year Salary

20 ----------------------------------------------------------- R p.a.

20 --------------------------------------------------------- R p.a.

20 --------------------------------------------------------- R p.a.

20 --------------------------------------------------------- R p.a.

20 --------------------------------------------------------- R p.a.

Total R ____________________

Average for the 5 years or lesser period if employee

employed for lesser period ................................................…… R ____________________

Certified correct to the best of my knowledge and belief.

_____________________________
Date Manager / Secretary

ESJ/mc/A/F/OCT 17
4.