Bar Code SEE INSTRUCTIONS OVERLEAF TYPE OF …

1 81/99567 Bar CodePension Fund (GEPF) National TreasuryGovernment EmployeesSEE INSTRUCTIONS OVERLEAFPage 1 of 4 ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALIDAND THE RELEVANT PARTIES MUST INITIAL THIS PAGEC ommissionerof Oaths InitialApplicant'sInitialTYPE OF TRANSACTION (Select only one type) - PENSION FOR: SPOUSE OR ORPHAN(S)A) PARTICULARS OF DECEASED (Compulsory)B) PARTICULARS OF PERSON APPLYING FOR PENSION (Compulsory) 4. date of marriageC C Y Y M M D D5. Marital type:A. ReligionB. Customary UnionC. CivilD. Life Partner3. Maiden name1. date of birthC C Y Y M M D D2. Income tax ) PARTICULARS OF SPOUSE/LIFE PARTNER (Only needed for spouse's pension applications)7. Residential addressC O D EC O D E6. Postal address5. E-mail address3.

2 Tel O D E4. Cell No. C) CONTACT PARTICULARS OF APPLICANT (Compulsory) 9. Title10. date of birthC C Y Y M M D D11. date of deathC C Y Y M M D D8. Middle names7. Firstname6. Surname4. ID No.(or) 5. Passport Death Cert. Pension/CP Type of Member:6. Title7. Relationship to deceased:5. Middle names4. Firstname3. Surname(or) 2. Passport ID Child (over 18)Guardian of Children13751 5. Was the deceased married more than once?6. PARTICULARS OF PREVIOUS / OTHER SPOUSE OR GUARDIAN OF CHILDREN OF THE ) ) ) Other ) Postal addressC O D E(Contributing MemberPensionerSpouse YesNoIf Yes, complete below:(Any type of marriage: Religious, Customary Union or Civil)(May 2005)1. Preferred Contact:PostalFaxE-mail(Select one)2.

3 Fax O D E(Refer to compulsory attachments on OVERLEAF ) ) Residential addressC O D ) Tel No. C O D E ) Cell No. E. PARTICULARS OF CHILDREN OF THE DECEASED OR FROM PREVIOUS MARRIAGE / LIFE PARTNERSHIPZ143 Page 2 of 4 ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALIDAND THE RELEVANT PARTIES MUST INITIAL THIS PAGEC ommissionerof Oaths InitialApplicant' ) Spouse's Status: (Compulsory for Spouse's or Orphan's Pension applications) ) Surname ) date of birth ) Firstname ) Other initials ) Child of.

4 Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status: Under 18 Full Time Student Disabled ) Registered dependant of medical aid scheme: No Yes C C Y Y M M D ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status: Under 18 Full Time Student Disabled ) Registered dependant of medical aid scheme: No Yes C C Y Y M M D ) Surname ) date of birth ) Firstname ) Other initials ) Child of.

5 Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status: Under 18 Full Time Student Disabled ) Registered dependant of medical aid scheme: No Yes C C Y Y M M D ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status.

6 Under 18 Full Time Student Disabled ) Registered dependant of medical aid scheme: No Yes C C Y Y M M D ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status: Under 18 Full Time Student Disabled ) Registered dependant of medical aid scheme: No Yes C C Y Y M M D D13751(If no Children State NONE in the Surname Field)18 and Older18 and Older18 and Older18 and Older18 and OlderA.

7 DeceasedB. Still MarriedC. ) Relationship to memberSpouseGuardian of Children:Applicant'sInitialCommissionero f Oaths ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status: Under 18 Full Time Student Disabled 18 and Older ) Registered dependant of medical aid scheme: No Yes C C Y Y M M D ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship.

8 Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status: Under 18 Full Time Student Disabled 18 and Older ) Registered dependant of medical aid scheme: No Yes C C Y Y M M D ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status: Under 18 Full Time Student Disabled 18 and Older ) Registered dependant of medical aid scheme.

9 No Yes C C Y Y M M D DC C Y Y M M D DC C Y Y M M D DC C Y Y M M D DC C Y Y M M D DPage 3 of 4 ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALIDAND THE RELEVANT PARTIES MUST INITIAL THIS ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status: Under 18 Full Time Student Disabled 18 and Older ) Registered dependant of medical aid scheme: No Yes ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status.

10 Under 18 Full Time Student Disabled 18 and Older ) Registered dependant of medical aid scheme: No Yes ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status: Under 18 Full Time Student Disabled 18 and Older ) Registered dependant of medical aid scheme: No Yes ) Surname ) date of birth ) Firstname ) Other initials ) Child of: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF