Government EmployeesPension Fund Bar Code …

1 Executor of EstateBar CodeA) PERSONAL PARTICULARS OF MEMBER/)1. Member Surname4. Firstname5. Middle names6. Maiden name10. Marital status:SingleMarriedDivorcedWidow/erLife Partner7. ID Date of birthSEE INSTRUCTIONS OVERLEAFFUNERAL BENEFIT CLAIM National TreasuryGovernment EmployeesB) PARTICULARS OF APPLICANT 1. Surname3. Firstname5. Maiden name6. ID No.(or) 7. Passport Date of birthC C Y Y M M D D4. Other initials9. Relationship to member: contact method:C) CONTACT PARTICULARS OF APPLICANT (Both postal and residential addresses must be supplied)(Compulsory)4. Tel No. C O D E6.

2 Fax No. C O D E7. Cell No. 8. E-mail address PostalFaxE-mail2. Postal address 3. Residential address C O D ED) PARTICULARS OF DECEASED (Compulsory)4. Surname6. Firstname9. ID No.(or)10. Passport Date of birth C C Y Y M M D D7. Other initials8. Relationship to Member:3. Was the deceased the Contributing Member or Pensioner?Yes NoIf no, complete particulars below:1. Death Cert. number2. C C Y Y M M D DE) CERTIFICATION BY APPLICANTI hereby certify that the particulars on this form, which have been verified against the relevant documents and records, are true and signedC C Y Y M M D D Z3002.

3 TitleC C Y Y M M D D(or) 8. Passport O D E32828 pension fund (To be completed if the Applicant is not the Member/Pensioner, as perSection A)(Compulsory)PENSIONERDate of death SpouseParentMajor ChildBrother/Sister SpouseChild under 18 Student under 22 Disabled child over 18 Signature of Applicant (or thumb print if he/she cannot read/write)(Compulsory)Guardian of child(Where income exceeds R60 000-00 per annum)IncomeTax Employer name (Onlyfor members)12. Middle namesNearest major Post Office with on-line access(needed for Post Office payments only) 8. 1. (Only needed if Applicant is also a member/pensioner)Member National Treasury Government Employees pension FundOverleaf for Z300 form April 2005 Page 1 of 2 Overleaf for the Funeral Benefit Claim Form (Z300) of th e Government Emplo yees Pensi on fund (GEPF) An amount (taxable lump sum Rand-value) of R7 500-00 is payabl e upon death of the member/pensioner as well as upon death of a spouse of the member/pensioner.

4 An amount (taxable lump sum Rand-value) of R3 000-00 is payable upon death of an eligib le child of the member/pensioner. A. Documentation Required The fol lowing compulsory documentat ion must accompany the Funeral Bene t Claim Form and submitted with th e form to the GEPF: 1. Original certi ed copy of the Death Certificate (issued by the Department of Home A airs); 2. A copy of the bar- code ID, Passport or Birth Certificate (in case of a minor child) of the deceased; 3. Originally certi ed copy of an ID (must be bar-coded), Passport or Birth Certificate(in case of a minor child) of the applicant exceptions as per ID Policy; and 4.

5 Original duly completed 5. If banking details are faxed to the GPAA, please attach a certi ed copy of the bank statement of the account re ected on the ACB BAnking Particulars form (Z894). ACB Banking Particulars Form (Z 894) where payments are to be made to a bank account rather than via the Post O ce. Certi cation must not be older than 6 months when compared to the date of application. The following additional documentation must accompany the Funeral Bene t Claim Form, where applicable: 5. If a spouse is deceased or is the applicant, an original certi ed copy of the Marriage Certificate is required or alternatively an a davit; 6.

6 If a child is deceased or is the applicant in the case of a major child, proof of age is required by means of an orig in al certi ed copy of a Bi rt h Certi cat e, ID or Passport; 7. If an adopted child is deceased or is the appli cant in the case of a majo r child, an adoption order is required upon which the names of the adopted parents appear; 8. If the bene t is payable to the estate, a copy of the letter of executorship is required; or 9. If a child is deceased and a full ti me st udent over 18 years but under 22 years, proof of registration is required from the in stit ution.

7 If the child is deceased and disabled and over 18, medical proof of the di sability is required and proof of nancial dependency on the member / spouse is required through an a davit that states the following: amount of nancial dependency and personal income of person concerned; or 10. If the surname of the person applying for the bene t is different to that of the covered per son or person entitled to payment (as depict ed on the ID, Passport or Death Certi cate documents), an a davit is required to proof the relationship. If there are any discrepancies when determining who is entitled to the money, documentary proof of responsibility for funeral cost will be requir ed from the applicant through means such as a quote or invoice fr om the funeral undert aker.

8 National Treasury Government Employees pension fund Overleaf for Z300 form April 2005 Page 2 of 2 B. Instructions for completing the application form (Z300) 1. One character must appear in each of the blocks that make up the field value. Use CAPITAL LETTERS and black ink. The text must stay within the boundaries of the block for each character. 2. In order to expedite the payment, the Funeral Benefit applications must be faxed to GEPF. Alternatively it can be posted or delivered. GEPF contact particulars for Funeral Benefits: Call Centre (Telephone enquiries): 0800 117 669 Fax Number Funeral Benefits Only: 012 319 3655 E-mail: Physical Address: Pensions Building 34 Hamilton Street Postal Address GEPF Funeral Benefits Arcadia Private Bag X62 Pretoria Pretoria 0001 3.

9 Breakdown (in preferred sequence of payment) of covered persons, who may receive the money and who may facilitate the application of the benefit: Entity Involved Covered Person Entitled to Payment Can be Applicants 1. Member > > > 2. Pensioner (whose pensions commenced after 30 November 2002) > > > 3. Spouse(s) of the member/pensioner > > > 4. Child under 18 of the member/pensioner > X > 5. Student (Child) under 22 of the member/pensioner > > > 6. Disabled child over 18 of the member/pensioner > > > 7. Guardian of a minor child of the member/pensioner X > > 8.

10 Parent (or parent in law) of the member/pensioner X > > 9. Brother/sister (or brother/sister in law) of the member/pensioner X > > 10. Executor of the estate of the deceased X > > 4. For payments via electronic bank transfer, the original documents must be forwarded to GEPF (posted or delivered) before the payment will be finalised. 5. In the absence of a Bank Particulars form (Z894), the payments will be directed via the Post Office. Post Office payments are facilitated quicker than electronic bank transfers (typically within 72 hours). The person entitled to the money will be notified by GEPF of the On-line Post Office (Post Office with electronic access) where the money is to be collected.