NATIONAL TREASURY GEPF USE ONLY - GEPF STAMPS BAR …

1 C) PERSONAL PARTICULARS OF DECEASED MEMBERNATIONAL TREASURY government Employees pension fund ( gepf )MEDICAL SCHEME MEMBERSHIP Z583 Private Bag x63 Pretoria SOUTH AFRICA 000134 Hamilton Street Arcadia PretoriaGEPF USE only - gepf STAMPSBAR CODEPARTICULARS OF MEDICAL SCHEME MEMBERSHIPThis form enables the gepf to successfully process the application for continued Medical assistance or to indicate a change in Medical Scheme Particulars. COMPULSORY ATTACHMENTS: See section No : (+27) (0) 12 319 1911 Fax No : (+27) (0) 12 326 2507 Call Centre : (+27) (0) 12 319 1000E-mail : : NumberSurnameTitleInitFirst NoMarital StatusE) CONTACT PARTICULARS OF APPLICANTP ostal CodeTel NoResidential AddressPostal CodePostal AddressCell NoMiddle NameMaiden NameMarriedUnmarriedWidow/erDivorcedLife PartnerE-MailA) TYPE OF APPLICATION -Please select only one option1.

2 Application for continued Medical Assistance after Retirement/Death in Service (Resolution 3 of 1999 and Resolution 1 of 2006) (Compulsory items: B,D,E,F,G,H,I,J and K. C in case of death)2. Continued Membership of Medical Scheme -Change of Medical Scheme Particulars(Compulsory items: B,D,E,F,G,H and K)B) COMPULSORY ATTACHMENTSAll copies of ID documents should be clear, and should not be older than 6 Certified copy of ID of the main member of the Medical Proof of all the dependants registered on your medical scheme. Certified copy of ID and or birth Membership Certificate from your medical applicable to Type 2 Applications:Copy of last Salary AdviceCompleted Z894 -Bank particularsService Certificate4. Member Death Certificate (if applicable)D) PERSONAL PARTICULARS OF APPLICANTP ension NumberSurnameTitleInitFirst NoIncome Tax NoMarital StatusMiddle NameMaiden NameMarriedUnmarriedWidow/erDivorcedLife PartnerDate of DeathALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID AND THE MEMBER OR PENSIONER AND COMMISSIONER OF OATHS MUST INITIAL THIS initialCommissioner of Oaths initial3.

3 Application of Widow / Widower for continued Membership of Medical Scheme(Compulsory items: B,C,D,E,F,G and K)5. Please include previous medical scheme certificate(s).PLEASE RETURN ALL PAGES, EVEN WHEN PAGES ARE NOT COMPLETEDPage-1 of 3Z583 - MEDICAL SCHEME MEMBERSHIPN ovember 2007 RevisionG) PARTICULARS OF MEDICAL SCHEMEM edical Scheme NameThe Medical Scheme details refer to the current and new medical schemeMedical Scheme NumberWould you like to continue your membership?YesNoDate of BenefitMembership Commencement DateH) PARTICULARS OF PREVIOUS MEDICAL SCHEMEM edical Scheme NameMedical Scheme NumberDate on which membership was terminatedI) CHOICE FOR MEDICAL BENEFIT UPON RETIREMENT / DEATHA single choice between Option A or Option B is compulsory -Please indicate clearly1.

4 OPTION A -Continued State Subsidised Membership2. OPTION B -Gratuity Payment (Once-off cash amount)ORSubject to 12 months continued membership of a registered medical fund on the last day of serviceALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID AND THE MEMBER OR PENSIONER AND COMMISSIONER OF OATHS MUST INITIAL THIS initialCommissioner of Oaths NameSurnameID No / Passport numberType *F) PARTICULARS OF DEPENDANTS -For any dependant registered on your medical scheme1.* 1-Spouse 2-Child 3-Disable 4-Student 5-Life Partner 7-Mother 8-Father 9-Grandchild A-Sister NumberSubject to 12 months continued membership of a registered medical fund on the last day of serviceEmployer NameStart DateEnd DateEmployer NameStart DateEnd DateEmployer NameStart DateEnd DateEmployer NameStart DateEnd Date and previous government service exceeding:-15 Years in respect of retirement-10 years in respect of medical dischargeonly if less than.

5 -15 Years in respect of retirement-10 years in respect of medical dischargePLEASE RETURN ALL PAGES, EVEN WHEN PAGES ARE NOT COMPLETEDPage-2 of 3Z583 - MEDICAL SCHEME MEMBERSHIPN ovember 2007 RevisionK) CERTIFICATION PARTICULARSI declare that all the particulars furnished on this form is true and or Thumbprint of MemberDeclared and signed before meCommissioner of OathsCommissioner StampDateDateSignature 1 ToDepartment or InstitutionDesignationSurname of EmployerRepresentativeTel NoFax NoJ) TO BE COMPLETED BY THE LAST EMPLOYER DEPARTMENTI certify that all particulars in this form are true and Date Stamp of EmployerState Contribution to member medical aid on last day of serviceLast day of employmentReason for retirementService record in government departments or related institutions.

6 All periods of service must be furnished:FromE-Mail addressPension NumberPLEASE RETURN ALL PAGES, EVEN WHEN PAGES ARE NOT COMPLETEDPage-3 of 3Z583 - MEDICAL SCHEME MEMBERSHIPN ovember 2007 Revisio