Provident Fund Withdrawl Notification Form
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1Provident fund withdrawl notification form
Personal details
Full names and surname:
_____________________________________________________________________________
Employee number:
______________________________
Gender:
M a l e
F e m a l e
Identity number:
______________________________
Date of birth:
_____________________________
Tax number:
______________________________
Tax office:
_____________________________
Date joined Company:
______________________________ Date joined fund:
_____________________________
Residential address:
______________________________________________________________________________
Postal address:
______________________________________________________________________________
Contact number:
______________________________
Annual income*:
R____________________________
*Annual income is all income for e.g. salary, remuneration, earnings, emolument, wages, bonus, fees, gratuities, commission,
pension, extratime payments, royalties, stipend, allowances and benefits, interest, annuities, share of profits, rental income,
compensation, honorarium.
Indebtedness**
Housing loan:
______________________________
Other: _______________________________________
Divorce agreement:
______________________________ (If so, please attach copy of agreement)
**A benefit may only be payable to a third party in the event of a housing loan, divorce or in the event of fraud, where a court
judgment has been obtained or the member has admitted liability in writing.
Fund details
Date of withdrawal:
_____________________________
Reason for withdrawl:
retrenchment
resignation
dismissal
Date of last contribution:
_____________________________
Last contribution:
member amount = R_____________
company amount = R_________________________
Benefit options:
please choose one option
I am not sure how I would like my benefit to be dealt with and I would like a Financial Planner to contact me.
I would like to take my benefits in cash***. I understand that in electing this option, my benefit will be subject to tax.
***It is important to note that a benefit is taxable in the year of accrual. Any delay in the pay-out will not mean that the benefit is
taxed in the later year of payout. Tax directives are obtained on your behalf through the internet and there is a charge
payable.
I would like to transfer my benefit to:
New employer’s retirement fund
Retirement annuity fund
Preservation fund
Name of fund:
_______________________________ Policy number: __________________________________
Contact person:
_______________________________ Contact number: _________________________________
I confirm that I have received financial advice with regard to my benefit options.
Member signature: _______________________________
This form will not be processed without a signature
Please note it is a mandatory requirement to supply a copy of the members ID Document and proof of bank account details in order
to finalise this claim.
Bank details
Payment to be made via:
Cheque
EFT
Bank: _________________________
Branch: ______________________________
Code: __________________________
Account type: ___________________
Holder: ______________________________
Number: _________________________
Company declaration
We hereby certify that, to the best of our knowledge, the above information is true and correct.
Name: ________________________
Designation: _____________________________ Company stamp:
Contact number: ________________
Date: ___________________________________
Authorised signature: _____________________________
This form will not be processed without a signature
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Parent category: Legal