WITHDRAWAL FROM FUND Bar Code - GEPF - Home

1 81/99870 Bar CodeTYPE OF TRANSACTION:A) PERSONAL PARTICULARS (Compulsory for all types of transactions)21. Occupation codeA. between fundsC. RetirementD. DeathE. DivorceZ102 National TreasuryPensions AdministrationWITHDRAWAL FROM FUNDSEE INSTRUCTIONS OVERLEAFY ears18. Pension retirement age (per service conditions)17. Date of service terminationC C Y Y M M D D13. Gender:MaleFemaleSingleMarriedDivorcedWi dow/erLife Partner14. Marital status:20. Employer code19. Employer name22.

2 Reason for termination of service23. Exit rule/s2. Trust fund registration number1. Payment must be forwarded directly to:A. BankB. Trust FundC. Pension FundB) PAYMENT PARTICULARS (This section is compulsory if type of transaction is A, B, C, D (E is optional))5. Bank name 4. Type of account:3. Name of account holder ChequeTransmission Savings11. Policy SARS registration number of fund12/89. fund registration number (in case of Actuarial Interest Transfer)8. Account Branch code6.

3 Branch name 1. Current pension Old pension C Y Y M M D D4. Date of birth 3. Title5. Surname6. Firstname7. Middle names8. Maiden name9. Salary Income tax Passport ID O D EC C Y Y M M D D16. Commencement date: Period covered by contributions3. Tel Fax O D EC O D E 5. Cell (or)D. Unclaimed(May 2005)15. Service ( Appointment) dateC) MEMBER'S CONTACT PARTICULARS12 6. E-mail addressPage 1 of 4C C Y Y M M D DC C Y Y M M D DC O D E1.

4 Postal address of member2. Residential address of member(This section is compulsory if type of transaction is A, B, C, D (E is optional))Employer Initial 1 Employer Initial 2 ALL PAGES OF THIS form MUST BE COMPLETED IN ORDER FOR THIS form TO BE VALIDAND THE RELEVANT PARTIES MUST INITIAL THIS PAGEY Y2. Last date which BoughtService Installment was deductedZ102 Period From Period To Annual Salary for PeriodPage 2 of 4E) SERVICE Periods of bought serviceFromC C Y Y M M D DToC 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 D C C Y Y M M D D4.

5 Any periods of breaks in service to be C Y Y M M D DC C Y Y M M D DC C Y Y M M D DFromToC 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 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 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 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 DC C Y Y M M D DF) DEPENDANT'S PARTICULARS Debt Debt Debt amountR R R R R R C CR R R R R R C CR R R R R R C CR R R R R R C CR R R R R R C CR R R R R R C CR R R R R R C CC C Y Y M M D DD)

6 DEBT Debt description Surname Date of birth Firstname Other initials Relationship: Spouse Adopted child Stepchild Natural child Child s status: Under 18 Full time student Disabled 18 and Older Spouse s status: Married Divorced Widowed Registered dependant of medical aid scheme.

7 No Yes C C Y Y M M D D Surname Date of birth Firstname Other initials Relationship: Spouse Adopted child Stepchild Natural child Child s status: Under 18 Full time student Disabled 18 and Older Spouse s status: Married Divorced Widowed Registered dependant of medical aid scheme.

8 No Yes C C Y Y M M D D Surname Date of birth Firstname Other initials Relationship: Spouse Adopted child Stepchild Natural child Child s status: Under 18 Full time student Disabled 18 and Older Spouse s status: Married Divorced Widowed Registered dependant of medical aid scheme: No Yes C C Y Y M M D D,R R R R R R R R C C,R R R R R R R R C C,R R R R R R R R C C,R R R R R R R R C Debt Debt amount4.

9 Debt total(Total liabilities debt to state/employer/ fund , including arrear contributions (specify salary overpayment separately)).C C Y Y M M D DC C Y Y M M D DC C Y Y M M D D61412to member:to member:to member:(Compulsory for transaction types A (10 years service), C and D)C C Y Y M M D D Divorce dateC C Y Y M M D D Divorce dateC C Y Y M M D D Divorce dateEmployer Initial 1 Employer Initial 2 ALL PAGES OF THIS form MUST BE COMPLETED IN ORDER FOR THIS form TO BE VALIDAND THE RELEVANT PARTIES MUST INITIAL THIS PAGER R R R R R C CR R R R R R C ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )

10 (Compulsory for all types of transactions (A, B ,C, D and E))(If no dependants state NONE in the surname field)Annual salary (basic pensionable salary) reflecting the increase periods during the last five years (or whole period if shorter)(Compulsory for debt to be deducted from benefits payable)Z102 Page 3 of 4YH) medical BENEFIT PARTICULARS 1. Does the member / spouse wish to continue with membership? R R R R R C C2. Name of medical scheme at retirement3. Scheme membership number4. Scheme/Package option name61412 Surname Date of birth Firstname Other initials Relationship: Spouse Adopted child Stepchild Natural child Child s status: Under 18 Full time student Disabled 18 and OlderSpouse s status.