1. Complete where applicable using block letters
   NOTES:
   1. This Form is to be completed by any person who wishes to apply for payment of accrued benefits
   2. Please use BLOCK LETTERS for completion of this Form
   3. Please write “N/A” if not applicable
   4. The information given in this Form can be used by the Approved Trustee concerned and the National
   Pensions Regulatory Authority (“the Authority”) in activities relating to the processing of your benefit
   and may be disclosed to other parties for such purposes.
   5. All fields marked * is mandatory

Details of the Member

Ground for Benefit Request & Documents Enclosed

 

Account Details- Member Benefits

a. Ensure that the bank account details supplied are in respect of your own account number.

b. Note however that for Provident Fund Benefits, the value that will be paid into the account stated below will be less any outstanding third party liabilities and bank charges relating to your payment.

c. Do make DOUBLE SURE that all account information is correct to prevent undue delays in the settlement of your benefit

 

Tax Relief Confirmation

 

Consent

3. Please be informed that you may withdraw your consent and opt-out of any or all of the marketing activities at any time.

Social Media Handle(s)

Member Declaration

1. I declare and certify that to the best of my knowledge and belief, the information given in this Form and its attachments is correct and complete; 

2. I am duly informed and understanding that I will be liable to prosecution for any false information or declaration herein or hereafter made to the Scheme.