WP1002 G.P.-S.026-0842 Pensions Administration …

1 WP1002I hereby give notice of my wish that the gratuity, which may be payable upon my death, be paid to the beneficiaries mentioned below and in theproportion indicated by ) BENEFICIARIESALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID AND THE MEMBER AND THE WITNESSES MUST INITIAL THIS PAGEM ember initialNOMINATION OF BENEFICIARIESBar CodeA) PARTICULARS OF MEMBERW itness1 InitialWitness2 Initial11. Employer Name10. pension fund9. Date of birth2. Salary SurnameFirst nameMiddle namesMiddle namesFirst name2. Surname3. SurnameMiddle namesFirst name6. Middle names5. First name3. Surname4. Title8. Passport ID No. National TreasuryPensions Administration1.

2 pension No.,%,%%,ID of benefitID of benefitPostal addressID of benefit SEE INSTRUCTIONS OVERLEAFDate of birthRelationshipC C Y Y M M D DC O D ECell No. Tel No. C O D EPostal addressCell No. Tel No. C O D ERelationshipDate of birthPostal addressC O D EDate of birthTel No. RelationshipC O D ECell No. 1 of 3C C Y Y M M D DC O D EC C Y Y M M D DC C Y Y M M D D61779WP1002 nomination OF BENEFICIARIESM iddle namesID of benefit,%4. SurnameFirst namePostal addressCell No. C O D ETel No. RelationshipDate of birthC O D EPostal addressC O D E7. SurnameFirst nameMiddle namesID of benefit,%Postal addressCell No.

3 C O D ETel No. RelationshipDate of birthC O D EVERY IMPORTANT!!!! INVALID IF TOTAL NOT = 100%TOTAL,%ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID AND THE MEMBER AND THE WITNESSES MUST INITIAL THIS PAGEM ember initialWitness1 InitialWitness2 InitialPage 2 of 35. SurnameFirst nameMiddle namesID of benefit,%6. SurnameFirst nameMiddle namesID of benefit,%Postal addressC O D EDate of birthRelationshipCell No. C O D ETel No. Date of birthRelationshipCell No. Tel No. C O D EC 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 D61779 Signature of Member (In presence of 2 witnesses)ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORMTO BE VALIDPLEASE NOTE: IMPORTANT INFORMATION ON OVERLEAFSIGNATURESWP1002 Thumb print only needed for cases wherethe member cannot read / writePlaceDateThumb print of memberPage 3 of 3C C Y Y M M D DWITNESSES (mandatory)SurnameFull namesPostal addressWitness 1 SignatureFull namesSurnamePostal addressWitness 2 SignatureC O D EWitness 1 Witness 2C) ESTATE (If available)1.

4 Name of executor 2. Address of executor C O D E3. Tel No. 4. Cell No. C O D EC O D E61779