WITHDRAWAL/RETIREMENT CLAIM FORM - CRF

1 CRF_Clm01 FEv20170701 1 WITHDRAWAL/RETIREMENT CLAIM form Please select ONE of the following options: withdrawal or retirement - Please complete Sections A, B, C, D, E, and F Reorganisation / Compulsory Early retirement - Please complete ALL sections THE FOLLOWING SECTIONS ARE TO BE COMPLETED BY THE MEMBER SECTION A: MEMBER S PERSONAL DETAILS MEMBER NO. _____ EMPLOYEE NO. _____ SURNAME _____ FIRST NAMES _____ DATE OF BIRTH _____ IDENTITY NUMBER _____GENDER: MALE FEMALE MAR ITAL STATUS _____ RESIDENTIAL ADDRESS _____ _____ POSTAL ADDRESS _____ _____ (Both of the above addresses are required by the SA Revenue Services - SARS).

2 TEL NO. (_____)_____ CELL PHONE NO. _____ E-MAIL ADDRESS _____ INCOME TAX REFERENCE NO. _____ TAX OFFICE _____ BANKING DETAILS ACCOUNT HOLDER S NAME _____ BANK NAME _____ ACCOUNT NUMBER _____ BRANCH NAME _____ BRANCH CODE _____ ACCOUNT TYPE: CURRENT SAVINGS TRANSMISSION FOREIGN ACCOUNT (Tick if applicable) COUNTRY _____ DIVORCE ORDERS Are you aware of any divorce order issued against your Fund benefit in favour of an ex-spouse? YES NO If yes, attach an original certified copy, of the complete divorce order to this form (if not already supplied to the Fund).

3 This order must be in terms of Section 7(8) of the Divorce Amendment Act 1989, to be binding on the Fund. Please provide full contact details of the ex-spouse in order for the benefit payment to be made by the Fund. FINANCIAL ADVICE The Fund has a preferred financial services provider. Any telephonic engagement with the preferred provider will be free of charge. Should you wish to enter into an agreement with the provider to receive financial advice, the fees will be as per agreement with the provider. I do not want to receive communication from the Fund s preferred financial services provider: CRF_Clm01 FEv20170701 2 SECTION B: BENEFIT OPTIONS DEFERRED MEMBER (PAID UP IN THE FUND) Members who wish to switch their assets to a different portfolio(s) at the point of electing deferred membership can do so by completing the Investment Switch Option Election form PAY FULL BENEFIT DIRECTLY INTO MY OWN BANK ACCOUNT AS SPECIFIED ABOVE PAY PORTION OF MY BENEFIT INTO MY OWN ACCOUNT AS SPECIFIED ABOVE Specify amount or percentage: TRANSFER OF BENEFIT.

4 FULL BENEFIT PORTION OF BENEFIT Specify amount or percentage: If Transfer of Benefit selected, please provide the details of the fund to which the benefit must be transferred. FUND DETAILS FUND NAME _____ TYPE OF FUND _____ CONTACT PERSON NAME _____ POSTAL ADDRESS _____ _____ TEL NO. (_____)_____ FAX NO. _____ E-MAIL ADDRESS _____ SECTION C: DECLARATION BY MEMBER I hereby confirm that: Payment of my benefit as specified herein represents the full and final discharge of the Fund's liability to me; The details provided herein, in particular my banking details are true and correct; I understand the options available to me with regard to the payment of my benefits, including the inherent tax implicationsand that I am making an informed choice.

5 In the event of any l oss suffered as a result of any details provided herein being incorrect, neither the Fund nor MomentumRetirement Administrators can be held liable for such OF MEMBER _____ DATE _____ THE FOLLOWING SECTIONS ARE TO BE COMPLETED BY THE EMPLOYERSECTION D: EMPLOYER DETAILS NAME OF EMPLOYER _____ TEL NO. (_____)_____ CELL PHONE NO. _____ E-MAIL ADDRESS _____ CRF_Clm01 FEv20170701 3 BANKING DETAILS (IF PRIOR CLAIM ) ACCOUNT HOLDER S NAME _____ BANK NAME _____ ACCOUNT NUMBER _____ BRANCH NAME _____ BRANCH CODE _____ ACCOUNT TYPE: CURRENT SAVINGS TRANSMISSION PAYMENT REFERENCE _____ (if applicable) SECTION E: CLAIM DETAILS DATE OF TERMINATION OF SERVICE _____ REASON FOR TERMINATION OF SERVICE.

6 withdrawal _____ (Resignation, Dismissal, Ill-health) retirement _____ (Voluntary Early, Normal, Late, Ill-health) REORGANISATION/CER _____ (Reorganisation/Compulsory Early retirement ) CONTRIBUTION DETAILS FINAL MONTH IN WHICH CONTRIBUTION WAS MADE _____ AMOUNT OF FINAL CONTRIBUTIONR _____ MEMBER R _____ EMPLOYER PRIOR CLAIM IS THERE A PRIOR CLAIM IN RESPECT OF SECTION 37D OF THE PENSION FUNDS ACT? YES NO If yes, please provide proof of the CLAIM and provide employer banking details. HOUSING LOAN GUARANTEE BY THE FUND TO THE BANK (FUND S HOME LOAN FACILITY): HOUSING LOAN GUARANTEE BY THE EMPLOYER: COMPENSATION FOR DAMAGE CAUSED BY THE EMPLOYEE*: *Note: Acknowledgement of liability and agreement to pay form to be completed and signed by the employer and member.

7 SECTION F: DECLARATION BY EMPLOYER It is hereby confirmed that the information contained herein is correct and, in particular, that the member and employer banking details provided above, have been confirmed as correct. The employer hereby unconditionally absolves the Fund and Momentum retirement Administrators and as necessary indemnifies and keeps indemnified the Fund and Momentum retirement Administrators from and against all or any loss, damage, cost and expenses which the beneficiaries, or any other person whatsoever, may sustain or incur, either directly or indirectly as a result of Momentum retirement Administrators, on behalf of the Fund, relying on and using any information supplied by the employer.

8 FULL NAME OF AUTHORISED OFFICIAL OF THE EMPLOYER _____ WORK TEL NO. (_____)_____ FACSIMILE NO. (_____)_____ E-MAIL ADDRESS _____ SIGNATURE OF AUTHORISED OFFICIAL OF THE EMPLOYER _____ DATE _____ EMPLOYER STAMP R R R CRF_Clm01 FEv20170701 4 THE FOLLOWING SECTION IS TO BE COMPLETED BY THE MEMBER ANDEMPLOYER SECTION G: JOINT DECLARATION (REORANISATION/COMPULSORY EARLY retirement ONLY) MEMBERI hereby confirm that I understand th e Rules of the Fund pertaining to the Reorganisation / Compulsory Early retirement benefit. EMPLOYER It is hereby confirmed that the above member has permanently left the employment of this employer as a result of Reorganisation / Compulsory Early retirement and that we, the employer, are liable to pay the employer portion of the Reorganisation / Compulsory Early retirement benefit as defined in the Rules of the Fund.

9 MEMBER AND EMPLOYER It is hereby confirmed that we, the member and the employer, confirm that we have agreed that the employer is liable for the payment of the following amount as their share of the liability due to the Fund. On payment of this amount, the member shall have no further CLAIM against the Fund or the employer in respect of the employer s liability. R_____ MEMBER SIGNATURE OF MEMBER _____ DATE _____ EMPLOYER FULL NAME OF AUTHORISED OFFICIAL OF THE EMPLOYER _____ WORK TEL NO. (_____)_____ FACSIMILE NO. (_____)_____ E-MAIL ADDRESS _____ SIGNATURE OF AUTHORISED OFFICIAL OF THE EMPLOYER _____ DATE _____ EMPLOYER STAMP REQUIREMENTS Please attach original certified copies of the following documents to this CLAIM form .

10 Member s identity document. Member s latest bank statementPLEASE NOTE The information disclosed within this document will be treated as confidential and will only be used for the purpose for whichit is intended in terms of applicable legislation. Payment will only be made on receipt of a tax directive is sued by the SA Revenue Services (SARS).The completed form together with supporting documents to be emailed to or posted to PO Box 4740, Tyger Valley, 7536