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. Tel O D E4. Cell No. C) CONTACT PARTICULARS OF APPLICANT (Compulsory) 9. Title10. Date of birthC C Y Y M M D D11.

2 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. 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: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship.

3 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: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status.

4 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: Contributing Member Pensioner Spouse ) Orphan: Yes No ) Relationship: Natural Child Adopted Child Stepchild (Refer to compulsory attachments on OVERLEAF ) ) Status.

5 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. 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.

6 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: 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.

7 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.

8 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 ) ) Status.

9 Under 18 Full Time Student Disabled 18 and Older ) Registered dependant of medical aid scheme: No Yes z143 Page 4 of 4 G. MEDICAL SCHEME PARTICULARS ( Compulsory where the state contributed to the member's medical subsidy ) 1. Does the spouse / life partner wish to continue with medical membership? YesNo 2. Name of medical scheme3. Scheme membership number4. Scheme/Package option name13751 4. Tel O D E 3. Initials and Surname of Contact PersonC O D E F) NAME AND ADDRESS OF EXECUTOR OF THE ESTATE (Complete where available)DECLARATIONTO BE SIGNED IN THE PRESENCE OF A COMMISSIONER OF OATHSS ignature of Applicant (OR Thumb Print of Applicant where he/she cannot read/write)I,do solemnly declare that I am either:A) the spouse (or life partner) of the deceased and that my marriage (or life partnership) as entered into on_____(date) was not dissolved by divorce or other means; or I declare the foregoing particulars are entirely correct in every respect and I undertake to advise GEPF immediately if any change occurs.

10 I am aware of the fact that should I fail to comply with the undertakings I will be responsible for any loss which may occur. B) a major eligible child (as per GEP Law) or the guardian of the children of the deceased. C O D EFull namesSurnameDesignationPostalAddress Official Stamp of theCommissioner of OathsSignature of Comm. of OathsDeclared and signed before me on this (date)This section needs to be completed by the Commissioner of Oaths:C C Y Y M M D DDate(Compulsory)PLEASE NOTE: PAYMENT WILL ONLY OCCUR ON RECEIPT OF THE ORIGINAL z143 form ; IMPORTANT INFORMATION ON OVERLEAFR R R R R R C C 6. Did the State contribute to the member's medical subsidy? Yes No6. What was the State's contribution to the member's medical aid Name2. Postal addressZ143If Yes, complete below:C C Y Y M M D D National Treasury Government Employees Pension Fund (G