MOTOR INDUSTRY FUND ADMINISTRATION …

1 application for death BENEFITMOTOR INDUSTRY fund ADMINISTRATIONREGIONCONTACT NUMBEREASTERN CAPE, PO BOX 7270, PORT ELIZABETH, 6055(043) 722 3126 KZN, PO BOX 10230, ASHWOOD, 3605(031) 274 0644 FREE STATE, PO BOX 22887, EXTON ROAD, 9313(051) 409 4001 HIGHVELD, PO BOX 2578, RANDBURG, 2125(011) 369 7750 NORTHERN REGION, PO BOX 13970, HATFIELD, 0028(012) 364 4800 WESTERN CAPE, PO BOX 17, BELLVILLE, 7535 (021) 941 7300 MIBCO National Number086 166 4226 FORM ATo be completed by the employer. Pages 1 - 3 What is required from the employer of the deceased?The employer need to provide the fund with details and supporting information of everyone who financially relied on the deceased BTo be completed by legal spouse / customary law spouse(s) / permanent life partner.

2 Pages 4 - 8 ORFORM CTo be completed by any major (over 18 years) person:Pages 9 - 12who was financially supported by the member,who was financially dependent on the member,to whom the member was legally liable for spouse(s), life partners, (need to complete FORM B)guardians of minor dependants (need to complete FORM D).ORFORM DTo be completed by any guardian / care giver of a minor child (under 18 years) who was dependent on the member. Pages 13 - 15 Note: Each claimant must complete an income and expenditure statement. Page 16 What is required from you, the person completing this form?It is in your own interest to fully complete and submit this form and all supporting documents as quickly as possible, as the Fundwill only be able to proceed with the claim once we have considered all the required information.

3 All these forms need to be supporting certified copy of the late member's ID certified copy of the late member s death certified copy of the marriage certificate or affidavit if not legally copies of birth certificates of ALL minor of adoption (if applicable).Certified copies of ID documents of ALL certified copies must be done at a police station or are the duties of the Trustees in terms of Section 37C of the Pension Funds Act?The duty of the Board of Trustees of the fund is the equitable distribution of death terms of Section 37C of the Pension Funds Act of 1956, the Trustees are required to:a) Identify and trace dependants and nominated beneficiaries of the deceased member of the ) Establish and investigate each dependant's financial and other ) Allocate the death benefit on a fair.

4 Being nominated/a claimant does not automatically entitle a person to a benefit, it only entitles a nominee/claimantto be considered when the distribution of the benefit is application forms with all supporting documentation must be submitted via your local MIBCO FOR death BENEFIT This form must be completed by the employerOriginal documentation to be submitted SECTION 1 DETAILS OF DECEASED ) Employee Council ) Employee ) Employee Full ) Employee ID number:Certified copy of ID document must ) Date of death :Certified copy of death certificate must ) Deceased employee personal Income Tax ) Residential ) Marital status:Legally marriedDivorcedWidow/ widowerEstrangedCustomary law marriageSinglePermanent life partnerSECTION 2 EMPLOYER ) Company ) Was the employee in service at the time of death ?

5 Yes ) Period ) If applicable - dates employee was absent from work immediately prior to for ) Termination date advised on the Monthly Returns to ) Contributions paid to last day of employment?yes ) Reason for termination of employment? ) Highest average salary actually earned by the employee during any five consecutive years in the service of theemployer during his membership to the SALARYR R R R R TotalR Average for 5 years or lesser period if employee was employed for a lesser periodR ) According to your records, did the employee in writing nominate a dependant/s?

6 Yes no If yes, please state name/s and contact detailsFORM ADETAILS OF DECEASED MEMBERC ouncil number:ID number:Full Names and Surname:02 SECTION 3 Please list allthe deceased's children and dependants that you are aware of )DETAILS OF SPOUSE/S, PERMANENT LIFE PARTNERSI nitialsSurnameDate of )DETAILS OF FORMER SPOUSESI nitialsSurnameDate of )DETAILS OF ANY OTHER DEPENDANTSI nitialsSurnameDate of )DETAILS OF CHILDRENFORM A (continued)03 SECTION 3(continued) ) Did the employee have any legal obligation to any third party in respect of a divorce agreement? ) Maintenance to ) Maintenance in respect of minor ) Did the employee support any other third parties parents yes to any of the above, please provide ) Is the spouse/s, permanent life partner of the deceased employee currently employed?

7 Was the employee registered on a medical aid?yesnounknownIf yes, please provide copy of front and back of medical aid of )Are the deceased employee's colleagues aware of any person/s who were dependent on the employee?yes noIf yes, please provide FOR AND ON BEHALF OF THE EMPLOYERI nitials and Surname:Designation:Contact number:Date:COMPANY STAMPSIGNATUREDETAILS OF DECEASED MEMBERC ouncil number:ID number:Full Names and Surname:FORM A (continued)04 application for death BENEFIT BY LEGAL SPOUSE / CUSTOMARY LAW SPOUSE / PERMANENT LIFE PARTNERO riginal application to be submitted FORM BSECTION 1 PERSONAL DETAILS OF )Full Names and ) ID number: Certified copy of ID document must ) ) Claimant's personal income tax ) Relationship to deceased member.

8 Legal spouseMarriage certificate (must beattached)Customary law spouseCustomary union certificate, proof of labola ORsection 5 of Form B (Page 8) to be completed by independent party (must beattached)Permanent life partnerSection 5 of Form B (Page 8) to be completed by independent party (must beattached) ) Date of marriage / Onset of Cohabitation as Life ) Residential ) Postal address: ) Contact details:Tel number:Cell number:E-mail ) Are you currently employed?yesnoIf yes, please provide latest no, date last employed and name of previous complete an income and expenditure statement. Page 16 DETAILS OF DECEASED MEMBERC ouncil number:ID number:Full Names and Surname:1)2)3)4)5)6) )DETAILS OF MAJOR CHILDRENI nitialsSurnameDate of BirthContact number1)2)3)4)5)6)7)8)Full Names and Surname of claimant:InitialsSurnameDate of BirthIn who's care is this minor child?

9 What is the health status of this minor child?InitialsSurnameDate of BirthIn who's care is this minor child?What is the health status of this minor child?InitialsSurnameDate of BirthIn who's care is this minor child?What is the health status of this minor child?InitialsSurnameDate of BirthIn who's care is this minor child?What is the health status of this minor child?InitialsSurnameDate of BirthIn who's care is this minor child?What is the health status of this minor child?InitialsSurnameDate of BirthIn who's care is this minor child?What is the health status of this minor child?05 application for death BENEFIT BY LEGAL SPOUSE / CUSTOMARY LAW SPOUSE / PERMANENT LIFE PARTNERFORM B (continued)DETAILS OF DECEASED MEMBERC ouncil number:ID number:Full Names and )DETAILS OF MINOR CHILDRENSECTION 2 List all minor (under 18) and major biological / legally adopted children of the deceased member and please indicate who iscurrently taking care of them and the current health status of the minor child(ren).

10 If applicable, please provide proof of ) What are your current living arrangements? live with parents, live alone with minor ) What were your living arrangements at the time of the member's death ? If living apart please provide ) To what extent were you and the memberfinanciallydependent on each other at the time of the member's death ? ) Please describe your current and future employment ) If applicable, please provide details of any other or previous spouse/s or permanent life partners and provide further details regarding the duration of these ) Please provide full details of any legal obligations the member had in terms of a divorce or any court order which required the member to pay maintenance in respect of any previous spouse, life partner or child(ren).