MEMBER BENEFIT CLAIM FORM (Please complete form in full) A. FUND INFORMATION Fund Name PUBLIC OFFICERS' DEFINED CONTRIBUTION PENSION FUND B. EMPLOYER INFORMATION Name of Ministry Department Employer Address Contact Person Contact Person Tel No C. MEMBER DETAILS Surname Full Names of Birth dd / mm / yyyy Initials Employee Number Passport Number of Employment dd / mm / yyyy Place of Issue Annual Taxable Salary mmm. cc Effective of Death/ Withdrawal/Retirement dd / mm / yyyy Amount of last contribution mmm. cc Joined Fund dd / mm / yyyy of last contribution dd / mm / yyyy Member's Fund No (Unique fund identifier no) Member's cellular phone no (code) Member's address Postal Physical No & Street Name Suburb City Country Postal Code D. PLEASE TAKE NOTE OF THE RELEVANT SECTIONS TO BE COMPLETED PER CLAIM TYPE Retirement and Disability - COMPLETE SECTIONS F E. TYPE OF MEMBER CLAIM Withdrawal - Reason for Withdrawal (tick applicable box) Resignation Dismissal Retrenchment *Death *Retirement - Reason for Retirement (tick applicable box) Normal Late Early Ill Health Disability *Permanent Total Disability Deferred Pensioner * Please take note of the additional supporting documents required for retirement, death and disability claims as per the administration guide * Beneficiary bank details must be completed as part of the disposal of Death Benefit document. Refer to the administration guide.
F. MEMBER PAYMENT OPTIONS (COMPULSORY MUST BE COMPLETED) Payment Option to be elected by the member when terminating membership as a result of retirement or disability from the fund (tick applicable box) 1. Full benefit to purchase Pension from Insurance Company OR Yes No 2. A maximum lumpsum of 25% and the balance to purchase Pension from an Insurance Company Yes No Does the member require to be contacted by NBC for benefit investment counseling advice Yes No G. ALLOWABLE DEDUCTIONS Court Orders Divorce Was the member divorced whilst a member of the fund? Yes No (If yes please attach an original certified copy of the divorce order) Maintenance Is there a maintenance order currently in force against the member? Yes No (If yes please attach an original certified copy of the maintenance order) Other Forms of Member Indebtedness Yes No If yes, state the amount and provide original certified proof of the indebtedness mmm. cc H. BENEFIT PAYMENT PARTICULARS * If the member or beneficiary is taking his benefits in cash, please indicate the banking details below:- Payment must be forwarded to the bank account of: Member *Retirement Fund Beneficiary Name of Account Holder Type of Account: Current Transmission Savings Bank Name Branch Name Account Number nnnnnn Branch Code * If the member is transferring all or any part of his benefit to an approved retirement fund, please indicate the details of the approved retirement fund below:- Name of Transferee Retirement Fund Name of Account Holder Type of Account: Current Transmission Savings Bank Name Branch Name Account Number Branch Code Fund registration number LRA registration number if applicable
* Should you wish to become a deferred pensioner (that is, a member who has left the permanent and pensionable establishment of the public service prior to the prescribed retirement age, but is still employed in the service of Government on contract, leaving his benefits in the Fund), then please indicate and complete the relevant option form. I. IMPORTANT NOTES It is important to obtain Financial advice, before electing a benefit payment option. All benefits may be subject to income tax depending on the applicable tax legislation. Attach all supporting documents as indicated in the administration guide. Failure to submit the required document timeously may result in certain risk benefit claims being repudiated. The administrator shall not under any circumstances accept any liability arising from any incorrect information provided in/with this member claim form, as the correct completion rests with member. Authorisation is hereby irrevocably given to the fund and or insurer to pay whatever benefit is due to the member or member beneficiaries by EFT into the bank account details provided. If incorrect banking details are provided, the administrator cannot be held liable, the onus lies with the member. J. FORWARDING ADDRESS Return to : The Public Officers' Defined Contribution Pension Fund, at : The Secretariat OR The Secretariat P.O.D.C.P.F P.O.D.C.P.F 2nd Floor Christie House P.O.Box 14395 Maseru Maseru, 100 Lesotho Lesotho K. DECLARATION and APPROVAL/AUTHORISATION (T)28327596 (F)28327597 Declaration by Member I certify that the information herein is correct. Declaration by Employer/Ministry I confirm that the member is fully aware of the contents of this form and any liabilities that he/she may have. Employers Stamp Declaration by Ministry of Finance only I confirm that the member is fully aware of the contents of this form and any liabilities that he/she may have. Ministry of Finance Stamp
Declaration by Principal Officer (P/O) I confirm that the member is fully aware of the contents of this form and any liabilities that he/she may have. P/O Stamp PFP. 1