Fillable Bar Code WITHDRAWAL FROM FUND 9. Salary No. (Kwazulu-Natal Department of Health)

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Bar Code WITHDRAWAL FROM FUND 9. Salary No. (Kwazulu-Natal Department of Health)

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G.P.-S 81/99870
Bar Code
TYPE OF TRANSACTION:
A) PERSONAL PARTICULARS (Compulsory for all types of transactions)
21. Occupation code
A. Resignation/Absconded B.Transfer between funds C. Retirement D. Death E. Divorce
Z102
National Treasury
Pensions Administration
WITHDRAWAL FROM FUND
SEE INSTRUCTIONS OVERLEAF
Years
18. Pension retirement age (per service conditions)
17. Date of service termination
C C Y Y M M D D
13. Gender:
Male Female
Single
Married
Divorced
Widow/er
Life Partner
14. Marital
status:
20. Employer code
19. Employer name
22. Reason for termination of service
23. Exit rule/s
2. Trust Fund registration number
1. Payment must be forwarded directly to:
A. Bank B. Trust Fund C. Pension Fund
B) PAYMENT PARTICULARS (This section is compulsory if type of transaction is A, B, C, D (E is optional))
5. Bank name
4. Type of account:
3. Name of account holder
Cheque
Transmission Savings
11. Policy No.
18/20/4
10. SARS registration number of fund
12/8
9.
Fund registration number (in case of
Actuarial Interest Transfer)
8. Account No.
7. Branch code
6. Branch name
1. Current pension No.
2. Old pension No.
C C Y Y M M D D
4. Date of birth
3. Title
5. Surname
6. Firstname
7. Middle names
8. Maiden name
9. Salary No. 10. Income tax No.
12. Passport No.11. ID No.
C O D E
C C Y Y M M D D
16. Commencement date: Period covered by
contributions
3. Tel No.
4. Fax No.
C O D E
C O D E
5. Cell No.
61412
(or)
D. Unclaimed
(May 2005)
15. Service (
Appointment) date
C) MEMBER'S CONTACT PARTICULARS
1
2
6. E-mail
address
Page 1 of 4
C C Y Y M M D D
C
C
Y
Y
M
M
D
D
C O D E
1. Postal address
of member
2. Residential
address
of member
(This section is compulsory if type of transaction is A, B, C, D (E is optional))
Employer Initial 1
Employer Initial 2
ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID
AND THE RELEVANT PARTIES MUST INITIAL THIS PAGE
Y Y
Validate Form
2. Last date i.r.o. which Bought
Service Installment was deducted
Z102
Period From Period To Annual Salary for Period
Page 2 of 4
E) SERVICE PARTICULARS
1.
3. Periods of bought service
From
C C Y Y M M D D
To
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
4. Any periods of breaks in
service to be
disregarded.
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
From
To
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
F) DEPENDANT'S PARTICULARS
1.a Debt description
2.a Debt description
1.b Debt amount
R R R R R R C C
R R R R R R C C
R R R R R R C C
R R R R R R C C
R R R R R R C C
R R R R R R C C
R R R R R R C C
C C Y Y M M D D
D) DEBT PARTICULARS
b
3.a Debt description
Surname Date of birth
Firstname Other initials
Relationship: Spouse Adopted child Stepchild Natural child
Child’s status: Under 18 Full time student Disabled 18 and Older
Spouse’s status: Married Divorced Widowed Registered dependant of
medical aid scheme: No Yes
C C Y Y M M D D
Surname Date of birth
Firstname Other initials
Relationship: Spouse Adopted child Stepchild Natural child
Child’s status: Under 18 Full time student Disabled 18 and Older
Spouse’s status: Married Divorced Widowed Registered dependant of
medical aid scheme: No Yes
C C Y Y M M D D
Surname Date of birth
Firstname Other initials
Relationship: Spouse Adopted child Stepchild Natural child
Child’s status: Under 18 Full time student Disabled 18 and Older
Spouse’s status: Married Divorced Widowed
Registered dependant of
medical aid scheme: No Yes
C C Y Y M M D D
,
R R R R R R R R C C
,
R R R R R R R R C C
,
R R R R R R R R C C
,
R R R R R R R R C C
2.b Debt amount
3.b Debt amount
4. Debt total
(Total liabilities debt to state/employer/fund, including arrear contributions (specify salary overpayment separately)).
C C Y Y M M D D
C C Y Y M M D D
C C Y Y M M D D
61412
to member:
to member:
to member:
(Compulsory for transaction types A (10 years service), C and D)
C C Y Y M M D D
Divorce date
C C Y Y M M D D
Divorce date
C C Y Y M M D D
Divorce date
Employer Initial 1
Employer Initial 2
ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID
AND THE RELEVANT PARTIES MUST INITIAL THIS PAGE
R R R R R R C C
R R R R R R C C
1.a)
2.a)
3.a)
1.c)
2.c)
3.c)
1.e)
2.e)
3.e)
1.g)
2.g)
3.g)
1.h)
2.h)
3.h)
1.b)
2.b)
3.b)
1.d)
2.d)
3.d)
1.i)
2.i)
3.i)
1.f)
2.f)
3.f)
(Compulsory for all types of transactions (A, B ,C, D and E))
(If no dependants state NONE in the surname field)
Annual salary (basic pensionable salary) reflecting the increase periods during the last five years (or whole period if shorter)
(Compulsory for debt to be deducted from benefits payable)
0
0
Z102
Page 3 of 4
Y
H) MEDICAL BENEFIT PARTICULARS
1. Does the member / spouse wish to continue with membership?
Yes No
5.
R R R R R R C C
2. Name of medical scheme at retirement
3. Scheme membership number
4. Scheme/Package option name
61412
Surname Date of birth
Firstname Other initials
Relationship: Spouse Adopted child Stepchild Natural child
Child’s status: Under 18 Full time student Disabled 18 and Older
Spouse’s status: Married Divorced Widowed Registered dependant of
medical aid scheme: No Yes
C C Y Y M M D D
Surname Date of birth
Firstname Other initials
Relationship: Spouse Adopted child Stepchild Natural child
Child’s status: Under 18 Full time student Disabled 18 and Older
Spouse’s status: Married Divorced
Widowed
Registered dependant of
medical aid scheme: No Yes
C C Y Y M M D D
Surname Date of birth
Firstname Other initials
Relationship: Spouse Adopted child Stepchild Natural child
Child’s status: Under 18 Full time student Disabled 18 and Older
Spouse’s status: Married Divorced Widowed Registered dependant of
medical aid scheme: No Yes
Surname
C O D E
C O D E
Surname
G) DEPENDANT'S AND OTHER CONTACT PARTICULARS
C O D E
C O D E
to member:
to member:
to member:
Total number of years in Government Service to be recognised
6. Did the State contribute to the member's medical subsidy? Yes No
7. What was the State's contribution to the member's medical aid scheme:
Y Y M M
(Compulsory for transaction types A (10 years service), C and D)
C C Y Y M M D D
Divorce date
C C Y Y M M D D
Divorce date
C C Y Y M M D D
Divorce date
Employer Initial 1
Employer Initial 2
ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID
AND THE RELEVANT PARTIES MUST INITIAL THIS PAGE
4.a)
5.a)
6.a)
4.c)
5.c)
6.c)
4.e)
5.e)
6.e)
4.g)
5.g)
6.g)
4.h)
5.h)
6.h)
4.b)
5.b)
6.b)
4.d)
5.d)
6.d)
4.i)
5.i)
6.i)
C C Y Y M M D D
4.f)
5.f)
6.f)
1.a)
2.a)
2.b)
1.b)
1.d)
2.d)
2.e)
1.e)
1.c)
2.c)
(If no dependants state NONE in the surname field)
(Compulsory if transaction type is C or D)
If Yes:
Next of kin
Next of kin
Spouse
Spouse
Guardian of child
Guardian of child
Relationship to member:
Relationship to member:
Initials
Initials
Telephone No.
Telephone No.
Postal
Address
Postal
Address
PLEASE NOTE: IMPORTANT INFORMATION ON OVERLEAF.
I) CERTIFICATION PARTICULARS BY EMPLOYER (Compulsory for all types of transactions)
For official use by the Employer only
I certify that
(a) All particulars furnished in this form are true and correct.
(b) All pension contributions payable by the member have been recovered and paid over in full.
(c) The member is fully aware of the contents of this form and any liabilities that he /she may have.
OFFICIAL DATE STAMP
OF EMPLOYER
Signature 1
Designation
Employer contact surname
Telephone No.
Fax No.
E-mail address
C O D E
Initials
C O D E
Signature 2
Employer contact surname
Initials
Compiled by:
Certified by an Assistant Director or equivalent designation:
Designation
Compulsory
61412
C O D E
C O D E
Telephone No.
Fax No.
E-mail address
Page 4 of 4
National Treasury Pensions Administration
Overleaf for Form Z102 May 2005 Page 1 of 2
Instructions for Completing Form Z102: Withdrawal of a Member from
a Pension Fund Administrated by Pensions Administration
1. Refer to checklists for attachments required for this form.
2. Where particulars are incorrect, outdated or changed after the original submission, the relevant
Personnel Office should make the necessary corrections directly on the Payroll Administration
System and re-submit the required document and attachments. The new set of documents must
clearly be marked as “Revised Version” on top of the main document:
− In this case the personal particulars changed, an Updating Personal Particulars of
Member Form (Z864).
− In this case the bank particulars changed, an ACB Bank Particulars Form (Z894).
− In case the withdrawal particulars changed, a Withdrawal from Fund Form (Z102).
3. A letter will be issued to the member and/or employer upon receipt of the application. This letter
contains the member’s unique Pension Number that should be used as a reference when interacting
with the Pensions Administration.
4. If the data received is insufficient to withdrawal the person to the Pension Fund, the Pension
Administration System will generate a system error. The Employer and/or Member will be notified of
the error via Pensions Administration Service Centre.
5. It is strongly advised that Withdrawal from Pension Fund Transactions must be submitted to the
Pensions Administration at least 6 to 8 weeks before the last day of service of the member.
Exceptions to the rule are resignations and cases of unpredictable death in service.
6. Withdrawal Transaction Types:
− Compulsory to select a transaction.
− Mark with an “X” as applicable:
[A] RESIGNATION / ABSCONDED: If the member has resigned, absconded, been
dismissed for misconduct or been discharged due to ill-health caused by own fault. Refer
to the following: Withdrawal of a Member from a Pension Fund due to
Resignation/Absconding.
[B] TRANSFERS BETWEEN FUNDS: For a transfer of a member’s pension value
between valid Pensions Administration Funds mentioned on Page 16, refer to the
following: Transferring Between Funds Administrated by the Pensions Administration.
[C] RETIREMENT/DISCHARGE: Only for retirements – all types of retirements, including
“external transfers”, but not cases mentioned in [A] and [D], refer to the following:
Withdrawal of a Member from a Pension Fund due to Retirement/Discharge and
Payment to an Approved External Pension Fund.
[D] DEATH: Only in cases of death in service, refer to the following: Withdrawal of a
Member from a Pension Fund due to Death.
[E] DIVORCE: Where an order is made for the payment of a pension value in a divorce
action, refer to the following: Notification by Member of Divorce Settlement.
7. COMMENCEMENT DATE (PERIOD COVERED BY CONTRIBUTIONS): Fill in the earliest date from
which the member started financially contributing to a Pension Fund.
8. EXIT RULE(s): The relevant pension benefit rule(s) according to the applicable Pension Fund Act
and Regulations must be quoted in full.
9. New Payment Requests via the Post Office, Cheque or Warrant Vouchers are no longer allowed.
10. FUND REGISTRATION NUMBER and SARS REGISTRATION NUMBER: Only applicable if
transferring the benefit value to an approved external Pension Fund.
11. The member must be made fully aware of the total financial liabilities and debt before employer
representative submits the form to the Pensions Administration.
National Treasury Pensions Administration
Overleaf for Form Z102 May 2005 Page 2 of 2
12. Dependant: The particulars of the spouse, children and any other person who, according to the
provisions of the rules concerned, qualify as dependants, must be stated in full.
13. A Spouse can be defined as a lawful husband(s) or wife (wives) or life partner(s) (including same sex
life partner).
14. A withdrawal of a member can only be done from the following Pension Funds Codes:
o Government Employees Pension Fund (GEPF) (Code 96)
o Temporary Employees Pension Fund (TEPF) (Code 04)
o Associated Institutions Pension Fund (AIPF) (Code 06)
15. The following Occupation Codes are applicable:
Occupation Code Occupation Description
1 Public Services
2 Provincial Services
3 Permanent Force
4 S.A. Police Service
5 National Intelligence Services (NIA)/South African Secret Service (SASS)
6 Department of Correctional Services
7 Associated Institutions (AIPF Fund)
8 Authorities Services
9 Head of Department (Director General)
A Magistrates
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Bar Code WITHDRAWAL FROM FUND 9. Salary No. (Kwazulu-Natal Department of Health)

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