Fillable S.A. - 1 Husbands/Wifes Claim reference number(s) ..

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S.A. - 1 Husbands/Wifes Claim reference number(s) ..

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S.A. - 1
Husband’s/Wife’s Claim
reference number(s)
………………………..
For official use only
Name ………………………….……………………………
Address …………………………………………………..…
…………………………………………………….
I.D. No. ……………………………………………….…….
N.I.S. No. …………………………………………….……..
Date of receipt of claim
……………………………………………………..
File No. …………………….…………....................
Local Board No. ………...…………………………..
Pension Grant No. …………………………………..
Rejected Claim No. …………………………………
FORM OF CLAIM FOR SENIOR CITIZENS’ PENSION
Instructions
1. A person desiring to claim Senior Citizens’ Pension must complete this form, sign it, and forward it with
his/her Birth Certificate or other evidence of age to the Chairman of the Local Public Assistance Board of the
district in which the claimant resides.
2. If a husband and wife are each claiming Senior Citizens’ Pension at the same time, each must fill out a
separate form.
Qualifications
1. The person must have attained the age of sixty-five years.
2. (i) The person must have been ordinarily resident in Trinidad and Tobago for a period of twenty years
immediately preceding the claim for pension; provided that a person shall not be deemed to have ceased
to be resident in Trinidad and Tobago merely by reason of temporary absence there from for an
aggregate period not exceeding five years during the said period of twenty years or;
(ii) For a period of fifty years in the aggregate.
3. The person’s income must not exceed $4,500.00 per month.
Important Notice
The following documents are required to substantiate a claim for Senior Citizens’ Pension (original and copies):
1. Electoral Identification Card.
2. Birth Certificate (computer generated) and Affidavit (where necessary).
3. Other evidence of age (e.g. Marriage Certificate/Baptismal Certificate).
4. Passport (previous and current).
5. Evidence of employment and wages/benefits receiving/received.
6. Evidence of National Insurance Benefits / other Pension / Benefits
7. Any other document as may be required by the Local Board.
2
Pension is not assignable
Male
1. Full Name of Applicant (Block Letters) …………………………………………………………..…. Female
(Surname) (Given Names)
2. Number of I.D. Card………………………. 3. Telephone Number ………………………
4. Address (give full details) …………………………………………………………………………….
………………………………………………………………………………………………………...
5. Father’s Name ……………………………………………………………………………...................
6. Mother’s Name ……………………………………………………………………………………….
7. Age last birthday ...................................................................................................................................
8. (a) Date and year of Birth ……………………………………………………………………………
(b) Birth Certificate Pin No …………………………………………………………………………
9. Place of birth (street or road, town and ward) ………………………………………………………..
9. Do you live permanently in Trinidad and Tobago? ………………………………………………….
10. How long have you been living permanently in Trinidad and Tobago? …………………………….
11. Dates of departure from, and return to, Trinidad and Tobago, within the last twenty years:
Date of departure …………………….……... Date of return …………………………
Date of departure ………………….………… Date of return …………………………
Date of departure ………………………….… Date of return …………………………
12. Marital status: Single Married Widow Widower
13. Given name of wife or husband ………………………………………………………………………
14. (a) Is/was wife or husband a Senior Citizens’ Pensioner? .…. If so, state District…………………...
(b) Give Reference Numbers …………………………………………………………………………
15. Are you living in the same house with your wife/husband? ………………………………...……….
16. List names, ages and addresses of children who are alive:
Name
Age
Address
17. Had you any other children? …………………….……… If so, list date of births …………………
………………………………………………………………………………………………………..
3
18. Is any sum payable by you (if a married man separated from his wife) to your wife by way of
maintenance …………………… If so, how much?..........................................................................
19. Have you been working in Trinidad and Tobago for the last twenty years? ………………………
20. By whom were you employed? ………………………………………………………………………
21. If not now working, give the name and address of your last employer? …………………… ……….
………………………………………………………………………………………………………...
22. State the kind of work you were doing ……………………………………………………………….
23. When did you cease to work? ………………………………………………………………………..
24. Have you any property? ………….. If so, what does it consist of?
...............................................................................................................................................................
25. (a) What is the value of property (house, land, etc)? …………………………………………………
(b) What income is derived from it? .....................................................................................................
26. Do you live on it? ……………………………………………....………………….............................
27. Is it rented or partly rented?...................................................................................................................
28. What rent do you get? ………………………………………………………………………………...
29. Have you any money in Savings Bank or in any Bank? ……………………………………………..
30. (a) How much have you coming in each month in money? ………………………………………….
(b) Are you a recipient of Public Assistance / Disability Assistance?......... If so, how much?.............
31. (a) Are you a Government or other pensioner? ……………………………………………………...
(b) If so, how much is your monthly pension? ………………………………………………………
32. Do you pay rent for the house in which you are living? ……………………………………………..
33. How much rent do you pay and to whom? …………………………………………………………...
34. Do you belong to any Friendly Society (Give Name) ………………………………………………..
35. Has your wife/husband any property? …………… If so, what does it consist of?
………………………………………………………………………………………………………...
36. Where is it situated? ………………………………………………………………………………….
37. What is the value of the property? ……………………………………………………………………
38. Does your wife/husband live on it? …………………………………………………………………..
39. If you are a widow, state date of your husband’s death? …………………………………………….
40. Have you applied for Senior Citizens’ Pension before? …………………………………...…………
41. Do you receive Senior Citizens’ Pension in any other district? ……………………………………...
4
WARNING
Any person, who for the purpose of obtaining or continuing a Senior Citizens’ Pension, either for
himself or for any other person, or for the purpose of obtaining or continuing a Senior Citizens’
Pension for himself or any other person at a higher rate than that appropriate to the case; knowingly
makes any false statement or false representation, and any person who knowingly obtains payment
of, or continues to receive a Senior Citizens’ Pension which he is disqualified from receiving or which
for any reason is not payable to him, is liable on summary conviction to imprisonment.
DECLARATION
I declare that all the statements in this form are true to the best of my knowledge and belief, and that I am
not, so far as I know, disqualified from receiving a Pension for any of the reasons stated on this form.
Applicant’s signature or (mark) ………………………………………….
Witness to declaration ……………………………………...
Address ……………………………………………………..
……………………………………………………….………
Telephone Number ………………………………………….
Occupation …………………………….…………………….
Date ………………………………………………………….
G.P., TR./TO. – AG 169 – 10,000 - /16
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S.A. - 1 HusbandsWifes Claim reference number(s) ..

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Completed 24 February 2022

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