Fillable NOMINATION OF BENEFICIARIES (Kwazulu-Natal Department of Health)

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NOMINATION OF BENEFICIARIES (Kwazulu-Natal Department of Health)

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The NOMINATION OF BENEFICIARIES (Kwazulu-Natal Department of Health) form is 3 pages long and contains:

  • 9 signatures
  • 0 check-boxes
  • 188 other fields

Country of origin: SOUTH-AFRICA
File type: PDF

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WP1002
I 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 the
proportion indicated by me.
B) BENEFICIARIES
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 PAGE
Member initial
NOMINATION OF BENEFICIARIES
Bar Code
A) PARTICULARS OF MEMBER
Witness1
Initial
Witness2
Initial
11.
Employer Name
10.
Pension
9.
Date of
birth
2.
Salary No.
1.
Surname
First name
Middle names
Middle names
First name
2.
Surname
3.
Surname
Middle names
First name
6.
Middle names
5.
First name
3.
Surname
4.
Title
8.
Passport No.
7.
ID No.
National Treasury
Pensions Administration
1.
Pension No.
,
%
,
%
%
,
ID No.
Percentage of benefit
ID No.
Percentage of benefit
Postal address
ID No.
Percentage of benefit
SEE INSTRUCTIONS OVERLEAF
Date of birth
Relationship
C C Y Y M M D D
C O D E
Cell No.
Tel No.
C O D E
Postal address
Cell No.
Tel No.
C O D E
Relationship
Date of
birth
Postal address
C O D E
Date of
birth
Tel No.
Relationship
C O D E
Cell No.
G.P.-S.026-0842
Page 1 of 3
C C Y Y M M D D
C O D E
C C Y Y M M D D
C C Y Y M M D D
61779
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signature
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signature
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signature
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WP1002
NOMINATION OF BENEFICIARIES
Middle names
ID No.
Percentage of benefit
,
%
4.
Surname
First name
Postal address
Cell No.
C O D E
Tel No.
Relationship
Date of
birth
C O D E
Postal address
C O D E
7.
Surname
First name
Middle names
ID No.
Percentage of benefit
,
%
Postal address
Cell No.
C O D E
Tel No.
Relationship
Date of birth
C O D E
VERY 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 PAGE
Member initial
Witness1
Initial
Witness2
Initial
Page 2 of 3
5.
Surname
First name
Middle names
ID No.
Percentage of benefit
,
%
6.
Surname
First name
Middle names
ID No.
Percentage of benefit
,
%
Postal address
C O D E
Date of birth
Relationship
Cell No.
C O D E
Tel No.
Date of
birth
Relationship
Cell No.
Tel No.
C O D E
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
61779
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signature
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signature
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signature
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Signature of Member (In presence of 2 witnesses)
ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM
TO BE VALID
PLEASE NOTE: IMPORTANT INFORMATION ON OVERLEAF
SIGNATURES
WP1002
Thumb print only needed for cases where
the member cannot read / write
Place
Date
Thumb print of member
Page 3 of 3
C C Y Y M M D D
WITNESSES (mandatory)
Surname
Full names
Postal address
Witness 1
Signature
Full names
Surname
Postal address
Witness 2
Signature
C O D E
Witness 1
Witness 2
C) ESTATE (If available)
1.
Name of executor
2.
Address of executor
C O D E
3.
Tel No.
4.
Cell No.
C O D E
C O D E
61779
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NOMINATION OF BENEFICIARIES (Kwazulu-Natal Department of Health)

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Completed 5 July 2021

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