death claim form details of dependants mutual/deathclaimforms.pdf · proof of...

1OMMS 10.2009 T000

Deathcertificate(certifiedcopyoforiginal)

Completedstatementofincome&expenses,assets&liabilities(seeAnnexureBandC–makeacopyforeachpotentialdependant).

Ifanyofthepartiesdonotwishtobeconsidered,AnnexureAmustbecompleted.

LastWill&TestamentorNextofKinAffidavit(J192).TheNextofKinAffidavitmustbecompletedifthememberdiedwithoutaLastWillandTestament,andmustbecompletedbythepersonwhoisreportingthemember’sestatetotheMasteroftheHighCourt.ThisformisobtainablefromtheofficesoftheMasteroftheHighCourtoraMagistrate’sCourt.

DeathNotice(J294).Thisformmustbecompletedbythepersonwhoisreportingthemember’sestatetotheMasteroftheHighCourt,andisobtainablefromtheofficesoftheMasteroftheHighCourtoraMagistrate’sCourt.

AcopyoftheLetterofExecutorship/Authority.

Acopyofthedeceased’slastsalaryadvice.

CopiesofBeneficiaryNominationForms.

Proofofage(certifiedcopyoforiginalIDdocuments/birthcertificates)forthedeceased,spouse,childrenand/ornominatedbeneficiary/ies.

Marriagecertificate(certifiedcopyoforginal)orswornaffidavit(i.r.o.customarymarriages).

Originalcertifiedcopyofdivorcecourtorderand/ormaintenancecourtorder(whereapplicable).

Proofofcontinuededucationinthecaseofeligiblechildrenovertheageof18butundertheageof23whoarestudents.

Medicalcertificate,inthecaseofachildwhoistotallyincapacitated.

Proofofcaregiver/guardianship(swornaffidavit;ifthecaregiverisnotthebiologicalparent,provideanexplanationofwherethenaturalparentis).

Managementboard’soremployer’sbenefitpaymentrecommendationtoTrustees,includingreasonsforallocation.

OriginalcertifiedcopyoftheTrustDeed,ifbenefitsaretobepaidtoaTrust.

Applicationform(ifpaymentmadetoaBeneficiaryFund).

Please read the following instructions carefully before completing this form

Q: Who must complete this form? Thisformmustbecompletedbyafamilymemberorotherpersonwithpersonalknowledgeofthedeceased’scircumstances.Wereservetherightto

corroborateallinformation. N.B. Theform,allAnnexuresandsupportingdocumentsmustbesignedinthepresenceofaCommissionerofOathsby(a)thepersonwho

completedtheformand(b)theCommissionerhim/herself.

Q: How is a Pension, Provident and Preservation Fund different from any other policy? ThedistributionofPension,ProvidentandPreservationFundDeathBenefitsisgovernedbySection37CofthePensionFundsAct. InorderfortheTrusteesoftheFundtodecidetowhomtheproceedsaretobepaid,thequestionsneedtobeansweredascomprehensivelyaspossible. Pleasenotethatincompleteinformationmaydelaythepaymentoftheclaim.Further information may also be requested at a later stage.

Q: What is the purpose of a Pension, Provident and Preservation Fund? ThepurposeofaPension,ProvidentandPreservationFundistoprovidefordependantswhoweredependentonthedeceasedduringhislifetime.

Q:WhoqualifiestobeconsideredbytheTrustees? Forthedispositionofdeathbenefits,thefollowingpersonsqualifyasdependantsintermsofthePensionFundsAct:

n Spouses,Life/CivilUnionPartners n Children(biological,adoptedandchildrenbornoutsideofmarriage) n Anyoneproventobefactuallydependentonthedeceasedformaintenance/financialsupport n Anyonetowhomthedeceasedwaslegallyliableformaintenance/financialsupport(e.g.intermsofdivorceagreementsandmaintenanceorders)or

wouldhavebecomelegallyliableformaintenance,hadthedeceasednotdied(e.g.engagedtobemarried,unbornchildren)

DuetoanamendmenttothePensionFundsActeffectiveon30June1989,abeneficiarywhowasnominatedbefore30June1989canonlybeconsideredifheorsheisadependantasdefinedinthePensionFundsActatthedateofdeath,oriftherearenootherdependants.Beneficiarieswhowerenominatedon or after30June1989,willbeconsideredalongwithotherqualifyingdependants.

Q: What is pre-required when instituting a claim? WerequirethedocumentslistedbelowandcompletionoftherelevantAnnexuresbyeachclaimantlistedonthisform.Notethateachclaimantmust

signtheirownAnnexures.Pleasereturntheseformstousassoonaspossible.

Death Claim FormDetails of Dependants(For consideration under Pension, Provident and Preservation Funds)

2OMMS 10.2009 T000

Section 37C of the Pension Funds Act

Q:WhatarethedutiesoftheTrustees? A) OneoftheimportantdutiesoftheBoardofTrusteesoftheFundisthedistributionofdeathbenefitsuponthedeathofamember.Intermsof

Section37CofthePensionFundsAct1956,Trusteesarerequiredto: n IdentifyandtracedependantsandnominatedbeneficiariesofthedeceasedmemberoftheFund(wheretracingcostsareincurred,suchcosts

willbedeductedfromtherespectiveallocatedbenefit), n Establishandinvestigateeachdependant’sfinancialandothercircumstances, n Allocatedeathbenefitsonafairandequitablebasis.

B) IntermsoftheprovisionsofSection37C,anybenefitpayablebyaFundatthedeathofamember,willbedealtwithasfollows:

(a) IftheFundwithintwelvemonthsofthedeathofthememberbecomesawareof,ortracesadependant(s)ofthememberandthememberhasnotnominatedanominee(s),thebenefitsshallbepaidtooneorallsuchdependants,asmaybedeemedequitablebytheTrustees.

(b) IftheFunddoesnotbecomeawareoforcannottraceanydependant(s)ofthememberwithintwelvemonthsofthedeathofthemember,andthememberhasdesignatedinwritingtotheFundanominee(s)whoisnotadependantofthemember,thebenefitofsuchportionofthebenefitasisspecifiedbythememberinwritingtotheFund,shallbepaidtosuchnominee(s),onlytotheextenttowhichthebenefitexceededtheoutstandingdebtagainsttheestate,ifthememberisinsolvent.

(c) IftheFunddoesnotbecomeawareoforcannottraceanydependant(s)ofthememberwithintwelvemonthsofthedeathofthememberandifthememberhasnotdesignatedanominee(s),thebenefitshallbepaidintotheestateofthemember.

(d) TheFundrespectsyourprivacyandtheconfidentialityofyourpersonalinformation.ThepersonalinformationthatyousupplytotheFundinthisformwillonlybeusedandprocessed:

n Forthepurposeofdistributionofthedeathbenefitstowhichthisformrelatesandanyotherpurpose(s)towhichyouhavespecifically consented. n TotheextentnecessarytoenabletheFundtomeetitsobligationstoyouandcomplywithitslegalobligations. n Nottobedivulgedtoathirdpartyotherthanasprovidedforinthelaw(i.e.PFAcomplaints).

ITISINYOUROWNINTERESTTOCOMPLETEANDSUBMITTHISFORMANDITSANNEXURESASQUICKLYASPOSSIBLE,ASWEAREONLYABLETOPROCEEDWITHTHISCLAIMONCEWEHAVEPROCESSEDANDCONSIDEREDALLTHEREQUIREDINFORMATION.

PLEASECOMPLETETHERELEVANTANNEXURESTHATAREPARTOFTHISFORM.

AnnexureA: RenunciationofRighttoClaimBenefits(tobecompletedbyanypotentiallydependentadult,whodoesnotwishtoclaimanybenefits)

AnnexureB: StatementofIncomeandExpenses(tobecompletedbysurvivingspouse)

AnnexureC: StatementofAssetsandLiabilities(tobecompletedbysurvivingspouse)

AnnexureD: SwornStatementbyPermanentLifePartner

AnnexureE: SwornStatementofdependencyonthedeceased

AnnexureF: Policereportrelatingtounnaturaldeaths

3OMMS 10.2009 T000

2.5 Onwhatdatewasthedeceasedlastactivelyatwork?

2.6 Isdeathduetoanaccident? Yes No

IfcoveredforAccidentalDeath,pleaseattachanoriginalcertifiedcopyofpoliceaccidentreport(seeAnnexureF).Ifdeathduetoanunnaturalcause,pleaseattachaswornaffidavitprovidingafullexplanationofcircumstancesleadingtodeathand/oranoriginalcertifiedcopyofpolicereport.

Cell

2.1 Nameofemployer

2.2 Ifself-employed,nameofcompanyorclosecorporation

Postaladdress

Telephone:Code

Nameandsurname

Fax: Code

No.

No.

E-mailaddress

Contactperson:

Postalcode

2. DETAILS OF DECEASED’S EMPLOYER

2.3 Prior claim by employer or divorce order?YesNo

Ifyes,pleaseattachproofasmentionedinbracketsbelow.

AllowableDeductions(validpriorclaims)

Accordingtocurrentlegislation,aFundmaymakeONLYthefollowingdeductionsfromamember’sbenefit:

n aloangrantedtothememberbythefundforthepurposesoffinancinghousingorhomeimprovements(proofofhousingloanagreementandsettlementvalue);

n anyamountforwhichthefundisliableunderaguaranteefurnishedinrespectofaloangrantedby,forexample,abankforthepurposesofhousing(pleaseindicateifrelevantandnameoffinancialinstitution);

n compensationinrespectofanydamagecausedtotheemployerasaresultoftheft,dishonesty,fraudormisconductofamember,andinrespectofwhichthememberhasinwritingadmittedliabilitytotheemployerorjudgementhasbeenobtainedagainstamemberinanycourtoflaw(writtenadmissionofliabilitybymemberi.r.o.theft,dishonesty,fraudormisconductofamember,and/orcourtcasenumberororiginalcertifiedcopyofcourtjudgement);

n deductionsintermsoftheDivorceAmendmentActof1989,wherebenefitspayableundertheFundhavebeenmadepartofadivorceorderbytheHighCourt(attachoriginalcertifiedcopyofthedivorcecourtorder).

2.4 WasanyperiodofserviceservedoutsideRSA?Yes No

Ifyes,completetablebelowandattachconfirmationletterfromemployerofservicerenderedoutsideRSA.

Periodfrom(DD/MM/YYYY) Periodto(DD/MM/YYYY) Country

D D M M Y Y Y Y

Please print in block letters using black or blue ink.

Evergreen Orion EasyBenefitPlan Protektor

1. DETAILS OF THE DECEASED

Schemecode(s) OldMutualmemberreferencenumber

Title

Surname

Identitynumber

Dateofbirth

Fullname(s)

Dateofdeath

Datewhenthedeceasedbecameapermanentemployee

Datewhenthedeceasedjoinedthescheme

Incometaxnumber(compulsoryforsalariesoverR60000p.a.)

Taxoffice

Lastresidentialaddressofthedeceased(notboxnumber)

Annualsalaryfortheprevioustaxyear(forpensioners,themonthlypensionandallotherincome) R

Postalcode

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

4OMMS 10.2009 T000

3. REGARDING THE MARITAL OR PARTNERSHIP STATUS OF THE DECEASED (COMPULSORY SECTION)

3.1 LIST OF ALL PREVIOUS AND SURVIVING SPOUSES (COMPULSORY SECTION)*Ifanyofthepreviousspousesaredeceasedorweredivorcedfromthedeceasedatdateofdeath,pleaseprovideuswithacopy(ies)oftheDeathCertificate(s)orDivorceOrdersANDAgreements.

Fullnames&surname Dateofbirth Datemarried Datedivorced*(ifapplicable)

Dateofdeath*(ifapplicable)

1.

2.

3.

4.

3.2.4 Ifthisspousedidnotlivewiththedeceased,sincewhenweretheylivingapart?

3.2.5 Ifspouseslivedapart,pleasesupplyuswiththefollowinginformation(Ifpreferred,theanswertothisquestionmaybesenttousseparately):

3.2.3 Didthisspouselivewiththedeceasedat date of death?

3.2.2 Bankingdetails

Nameofbank Branchcode

Accountnumber Typeofaccount

Yes No

3.2.5.3 Wasthedeceasedassistingthespousefinanciallyatdateofdeath?

Please attach hereto: (a) CompletedAnnexureB(StatementofIncomeandExpenses) (b) CompletedAnnexureC(StatementofAssetsandLiabilities) (c) Copyofmarriagecertificate(customaryorcivil) (d) Copyofidentitydocumentofspouse

3.2.5.1 Adescriptionoftherelationshipbetweenthespouseandthedeceased.

3.2.5.2 Iftherelationshipwaspoor,pleaseadviseusofthereason(s)therefor.

3.2.5.4 Ifso,werequirefulldetailsthereof.

Yes No

3.2 DETAILS OF SURVIVING SPOUSE

3.2.1 Fullnames

Residentialaddress

Postaladdress

E-mailaddress

Was/isthesurvivingspouseemployed: atdateofdeath? currently?

Telephone:(H) Code

Telephone:(W) Code

No.

No.

Surname

Maiden/previoussurname(s)

Dateofbirth

Datemarried

Cell

Identitynumber

Postalcode

Postalcode

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

PLEASEMARKALLAPPLICABLEBLOCKSWITHAN“X”.

Married(includingcustomaryandreligiousunions,civilmarriagesandcivilpartnerships) Completesections3.1,3.2and5

Marriedwithmorethanonespouseaccordingtocustomaryunion Completesections3.1,3.2,4and5

Married,butseparated Completesections3.1,3.2,5(and6iflivingwithapermanentlifepartner)

Divorced Completesections3.1and7

Widowed Completesections3and3.2

Nevermarried Completesection3

Permanentlifepartnership Completesections3.1and6

5OMMS 10.2009 T000

4.1 Fullnames

Residentialaddress

Postaladdress

Cell

E-mailaddress

Telephone:(H) Code

Telephone:(W) Code

No.

No.

Maiden/previoussurname(s)

Dateofbirth

Datemarried

Surname

Identitynumber

Postalcode

Postalcode

4. DETAILS OF OTHER SURVIVING SPOUSE(S) (Please make copies if necessary)

D D M M Y Y Y Y

D D M M Y Y Y Y

4.4 Ifthisspousedidnotlivewiththedeceased,sincewhenweretheylivingapart?

4.5 Ifspouseslivedapart,pleasesupplyuswiththefollowinginformation(Ifpreferred,theanswertothisquestionmaybesenttousseparately):

4.3 Didthisspouselivewiththedeceasedat date of death?

4.2 Bankingdetails



Yes No

4.5.3 Wasthedeceasedassistingthespousefinanciallyatdateofdeath?

Please attach hereto: (a) CompletedAnnexureB(StatementofIncomeandExpenses) (b) CompletedAnnexureC(StatementofAssetsandLiabilities) (c) Copyofmarriagecertificate(customaryorcivil) (d) Copyofidentitydocumentofspouse

4.5.1 Adescriptionoftherelationshipbetweenthespouseandthedeceased.

4.5.2 Iftherelationshipwaspoor,pleaseadviseusofthereason(s)therefor.

4.5.4 Ifso,werequirefulldetailsthereof.

Yes No

D D M M Y Y Y Y

6OMMS 10.2009 T000

5. SWORN AFFIDAVIT REGARDING MARRIAGE AT DATE OF DEATH Each surviving spouse has to complete this section (Please make copies if necessary)

5.2 TobecompletedbyaCommissionerofOaths:

SignatureofCommissionerofOaths Officialstamp

Designation

Fullnames/surname

Signedinfrontofme,thedeponenthavingstatedthathe/sheknowsandunderstandsthecontentsofthisaffidavit,thathe/shehasnoobjectionstothisoath,andthathe/sheconsiderstheoathbindingonhis/herconscience.

Address

Postalcode

5.1 Tobecompletedbythesurvivingspouse:

atthedateofhis/herdeath.

member(fullnames/surname)

bornon wasmarriedtothedeceased

IdeclarethatI,theundersignedsurvivingspouse(fullnames/surname)

Signedat this dayof 20

Signatureofsurvivingspouse

D D M M Y Y Y Y

6.4 Ifthedeceasedlivedapartfromthelifepartnerat date of death,pleasestatethefollowing:

n Sincewhendidtheyliveapart?

nWhatwerethereasons?

Thepermanentlifepartnermustpleasecomplete: (a) AnnexureB(StatementofIncomeandExpenses) (b) AnnexureC(StatementofAssetsandLiabilities) (c) AnnexureD(Swornstatementbypermanentlifepartner) (d) Alsosupplyuswithacopyoftheidentitydocumentofthisperson.

D D M M Y Y Y Y

6. PERMANENT LIFE PARTNER (living together as a couple)

6.1 Didthedeceasedlivewithsomeone,andshareahouseholdat date of death?

6.2 If“Yes”,pleasesupplydetails:

Fullnames

Surname

Identitynumber

Yes No

Dateofbirth

Residentialaddress

Postaladdress

Cell

E-mailaddress

Telephone: (H)Code

Telephone: (W)Code

No.

No.

Postalcode

Postalcode

D D M M Y Y Y Y

6.3 Bankingdetails



7OMMS 10.2009 T000

7. DIVORCED This section must be completed in respect of each previous spouse (Please make copies if necessary)

7.1 Howmanytimeshadthedeceasedbeendivorced?

7.2 Previousspouse’sdetails:

Fullnames

Surname Dateofbirth

Datemarried Datedivorced

Residentialaddress

Postaladdress

Cell

E-mailaddress

Telephone:(H) Code

Telephone:(W) Code

No.

No.

Postalcode

Postalcode

Please attach hereto:

(a) acopyoftheDivorceOrderANDAgreement;

(b) acopyoftheidentitydocumentofthepreviousspouse;

(c) acopyoftheMarriageCertificateifremarried;

(d) completedAnnexureE(Swornstatementofdependencyonthedeceased),ifapplicable.

Yes

Yes

Yes

No

No

No

Yes No

Yes No Yes No

7.4 Pleasestatewhethertheex-spouseandthedeceasedlivedtogetheraftertheirdivorce.

7.7 Ifnotremarried,istheex-spouselivingwithsomeoneashusbandandwife?

7.9 Werearrangementsmade/willtheystillbemadeforthepaymentofmaintenancetotheex-spouseafterdateofdeath?

Ifmaintenancewasvoluntary,pleasecompleteandattachAnnexureE.

7.6 Hastheex-spouseremarried?

eithervoluntarily

If“Yes”,pleasesupplycopyofmarriagecertificate.

orintermsofamaintenanceorder/agreement

7.5 Iftheex-spouselivedwiththedeceasedat date of death,pleasestatesincewhen.

7.8 Pleasestatewhetherthedeceasedwasmaintainingtheex-spouseat date of deathorhadundertakentomaintaintheex-spouse:

If“Yes”,pleasesupplydetails(i.e.claimagainstthedeceased’sestate).

7.10 Monthlymaintenanceatdateofdeathpayableinrespectof:

n Ex-spouse

n Child(ren)

R

R

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y D D M M Y Y Y Y

7.3 Bankingdetails



8OMMS 10.2009 T000

8. ALL CHILDREN OF THE DECEASED (BIOLOGICAL, ADOPTED, FOSTER, BORN OUTSIDE OF MARRIAGE AND PREDECEASED) REGARDLESS OF AGE

IfthedeceasedhadNOchildren,pleasemarkthisblockwithan“X”

Ifchildrendonotwishtobeconsideredfortheallocationofbenefits,pleasecompleteAnnexureAoraseparateaffidavit.IfAnnexureAiscompletedbyanyofthechildren,theymuststillbelistedbelow.AllmajorchildrenwhowishtobeconsideredmustcompleteAnnexureB&C,andsupplyuswithcopiesofthefollowingdocuments:

n Identitydocumentsofallchildren;n Adoptionpapersofalladoptedchildren;n Baptismalcertificatesandfullbirthcertificatesofchildrenbornoutofwedlock;n Ifdisabled,pleaseprovideappropriatemedicalevidence.

LISTOFALLCHILDRENOFTHEDECEASED(Ifmorespaceisneeded,pleasemakecopiesbeforecompletingthissection)

Full names and surname of the childIdentity number

of the childIn whose care is the child

currently?Fullnamesofthebiological/adoptive parents of the child

Child’spostaladdress

E-mailaddress

Telephone(BusinessHours)

Cellphone

Pleaseticktheapplicableblock: Relationshiptothedeceased:

Occupationofthechild(ifemployed)

Scholar Employed Biological

Foster

Adopted

Outsideofmarriage

Other

Student Disabled

Unemployed

Bankingdetails(whereapplicable)







E-mailaddress


Cellphone




Foster

Adopted

Outsideofmarriage

Other

Student Disabled

Unemployed








E-mailaddress


Cellphone




Foster

Adopted

Outsideofmarriage

Other

Student Disabled

Unemployed




9OMMS 10.2009 T000

LISTOFALLCHILDRENOFTHEDECEASED(continued)





E-mailaddress


Cellphone




Foster

Adopted

Outsideofmarriage

Other

Student Disabled

Unemployed








E-mailaddress


Cellphone




Foster

Adopted

Outsideofmarriage

Other

Student Disabled

Unemployed








E-mailaddress


Cellphone




Foster

Adopted

Outsideofmarriage

Other

Student Disabled

Unemployed




10OMMS 10.2009 T000

9. FINANCIAL DEPENDANTS OF DECEASED

10. ADDITIONAL INFORMATION

9.1 Stateallpersons(exceptthespouse/childrenalreadystated)whowerefinanciallydependentonthedeceased at date of death (i.e.agedparents,etc.).

Eachoftheperson(s)belowmustcompleteAnnexuresB,CandE.

(Ifmorespaceisneeded,pleasemakecopiesbeforecompletingthissection)

Pleaseprovideanyinformationregardingfamilycircumstancesorotherfactors,whichyouthinktheTrusteesshouldknowofandwhichwillhelpthemtodistributethebenefitsequitably.Detailsregardingthefinancialcircumstancesofdependantsandnominees,andfurtherneedsofdependants,willbeveryhelpful.Wheresurnamesdiffer,pleaseclarifywithdetailedexplanation.

9.2 Didthedeceasedhaveanyotherpossibledependantsatdateofdeath? Ifso,pleaseprovidefulldetailsinSection10below.

Yes No

Fullnames Surname

Identity Telephonenumbernumber or e-mail addressCurrentaddressor contact details

Relationshiptothedeceased



Fullnames Surname





Fullnames Surname





Fullnames Surname





11OMMS 10.2009 T000

Fullnames/surname

NameofFund

Nameofcompanywhoadministratesabove-mentionedFund

Membernumberofdeceased

Postaladdress

Postaladdress

Telephone:Code

Telephone:Code

Fullnamesandsurname

Fax: Code

Fax: Code

No.

No.

No.

No.

E-mailaddress

E-mailaddress

Employedby(nameofcompany/firm/person)

ContactpersonattheFund:

Postalcode

Postalcode

11. DETAILS OF EXECUTOR

12. DETAILS OF OTHER PENSION/PROVIDENT FUND OF WHICH THE DECEASED WAS A MEMBER

13. LIST OF ALL DECEASED’S POLICIES WITH OTHER COMPANIES AND ANY OTHER AMOUNTS PAYABLE AS A RESULT OF THE MEMBER’S DEATH (I.E. PENSION/PROVIDENT FUNDS)

Company/NameofFundandpolicynumber Deathvalue DatepaidNominatedbeneficiary(ies)orpersonlikelytoreceivebenefit

Yes NoHasthedeathbeenreportedtotheMasteroftheHighCourt?

12OMMS 10.2009 T000

n TheTrusteeshaveastatutorydutyintermsofsection37CofthePensionFundsActtoinvestigatealldependants(legalandfactual)ofthedeceasedmember,andtheActconfersuponthetrusteesadiscretiontoallocatedeathbenefitsavailableunderthepolicyorpoliciestodependantsofthedeceasedand/ornominatedbeneficiariesofthedeceased.

n Pleaseensurethatallinformation,includingdetailsofyourincome,expenditure,meansandassets,andyourrelationshipwiththedeceased,as

requestedonthisformincludingallofitsAnnexures,arefullyandaccuratelyrecordedtoassisttheTrusteesinmakingafairandappropriateallocationofdeathbenefitsundertherelevantpolicy/policies.

n PleasenotefurtherthattheTrusteesmaydeemitnecessarytosubmitforcommentandinput,theinformationprovidedbyyoutootherdependantsandnominatedbeneficiariesofthedeceased,toverifytheinformationprovided,whenconflictinginformationisreceivedbythemorshouldtheydeemthisnecessarytoestablishthefacts.

N.B.:Anymisrepresentations,eitherexpresslyorbyomission,willbeviewedinaseriouslight,andwillprejudiceyourprospectsofreceivinganyallocationofthedeathbenefitsorpartthereof,underthepolicy/policies.

14.2 TobecompletedbyaCommissionerofOaths.

SignatureofCommissionerofOathsOfficialstamp

Designation

Fullnames/surname

Signedinfrontofme,thedeponenthavingstatedthathe/sheknowsandunderstandsthecontentsofthisaffidavit,thathe/shehasnoobjectionstothisoath,andthathe/sheconsiderstheoathbindingonhis/herconscience.

Address

Postalcode

14. SWORN DECLARATION (COMPULSORY)

14.1 Tobecompletedbythepersonwhocompletedthisform.

I,

underoaththattheinformationinthisform,andinthesupportingdocumentsthatIsigned,istrueandcorrect,andindemnifytheSuperFundandOldMutualagainstanyclaimthatmayarisefromanyincorrectorfalseinformationprovidedinthisform.

(fullnamesandsurname)declare

Signedat this dayof 20

Signature

Telephone:Code

Capacityorrelationshiptodeceased

No.

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