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PERSONAL PARTICULARS A) PERSONAL PARTICULARS OF MEMBER/PENSIONER Married (Kwazulu-Natal Department of Health)

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Z864
Bar Code
PERSONAL PARTICULARS
A) PERSONAL PARTICULARS OF MEMBER/PENSIONER
National Treasury
Pensions Administration
SEE INSTRUCTIONS OVERLEAF
1.
Pension No.
2.
3.
Surname
4.
First name
5.
Middle names
6.
Maiden name
11.
Marital status
Single
Married
Divorced Widow/er
Life Partner
C C Y Y M M D D
B) PARTICULARS OF SPOUSE(S) / LIFE PARTNER
12.
Date of
marriage
7.
ID No.
8.
Passport No.
9.
Date of
birth
C C Y Y M M D D
10.
Income tax number
ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID AND THE
MEMBER OR PENSIONER AND COMMISSIONER OF OATHS MUST INITIAL THIS PAGE
Member/Pensioner
Initial
Commissioner of
Oaths Initial
Page 1 of 3
Marital type
Passport No.ID No.
Middle names
First name
4.
Surname
Date of birth
C C Y Y M M D D
Date of
marriage
C C Y Y M M D D
Maiden Name
Relationship
Status
Registered dependant of
medical aid scheme
Religion Customary Union Civil
Yes
No
Marital type
Passport No.ID No.
Middle names
First name
1.
Surname
Date of birth
C C Y Y M M D D
Date of
marriage
C C Y Y M M D D
Maiden Name
Relationship
Status
Registered dependant of
medical aid scheme
Religion Customary Union Civil
Yes
No
Marital type
Passport No.ID No.
Middle names
First name
2.
Surname
Date of birth
C C Y Y M M D D
Date of
marriage
C C Y Y M M D D
Maiden Name
Relationship
Status
Registered dependant of
medical aid scheme
Religion Customary Union Civil
Yes
No
Marital type
Passport No.ID No.
Middle names
First name
3.
Surname
Date of birth
C C Y Y M M D D
Date of
marriage
C C Y Y M M D D
Maiden Name
Relationship
Status
Registered dependant of
medical aid scheme
Religion Customary Union Civil
Yes
No
G.P.-S 81/326615
36690
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1.
Preferred contact
E) PERSON'S CONTACT DETAILS
(Both postal and residential addresses must be supplied)
4.
Tel No.
C O D E
5.
Fax No.
C O D E
6.
Cell No.
7.
Email address
Postal Fax Email
1.c)
Scheme/package option name
1.d)
Date on which membership was terminated
C C Y Y M M D D
1.b)
Scheme membership number
1.a)
Name of medical scheme
1. PARTICULARS OF PREVIOUS MEDICAL SCHEME
D) MEDICAL SCHEME PARTICULARS
2.d)
Scheme/package option name
2.c)
Scheme membership number
2.b)
Name of medical scheme
C C Y Y M M D D
2.a)
Commencement date
2. PARTICULARS OF NEW MEDICAL SCHEME OR CHANGES TO CURRENT SCHEME
2.
Postal address
3.
Residential address
C O D E
C O D E
ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID AND THE
MEMBER OR PENSIONER AND COMMISSIONER OF OATHS MUST INITIAL THIS PAGE
Member/
Pensioner
Initial
Commissioner of
Oaths Initial Page 2 of 3
C) PARTICULARS OF OTHER DEPENDANTS
2.
Surname
Date of birth
Relationship
C C Y Y M M D D
Registered dependant
of medical aid scheme
Status
Other Initials
First name
Yes
No
3.
Surname
Date of birth
Relationship
C C Y Y M M D D
Registered dependant
of medical aid scheme
Status
Other Initials
First name
Yes
No
4.
Surname
Date of birth
Relationship
C C Y Y M M D D
Registered dependant
of medical aid scheme
Status
Other Initials
First name
Yes
No
Z864
1.
Surname
Date of birth
Relationship
C C Y Y M M D D
Registered dependant
of medical aid scheme
Status
Other InitialsFirst name
Yes
No
2.e)
Total number of years in Government Service to be recognised
Y Y M M
36690
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signature
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ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID
PLEASE NOTE: IMPORTANT INFORMATION ON OVERLEAF
DECLARATION
Designation
Signature of Commissioner of Oaths
Signature of member/ pensioner
Declared and signed before me this day of
year of
in every respect and I undertake to advise Pensions Administration of any changes immediately.
, do solemnly declare that the above particulars are entirely correct
I,
Postal address
C O D E
Page 3 of 3
Z864
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member/pensioner
Official Stamp of the
Commissioner of Oaths
Thumb print only needed for cases where the
member or pensioner cannot read / write
36690
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PERSONAL PARTICULARS A) PERSONAL PARTICULARS OF MEMBERPENSIONER Married (Kwazulu-Natal Department of Health)

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Completed 21 June 2021

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