Benefit Withdrawal Form

Please complete all the required fields to process your benefit claim.

This is a Death Claim (For Death Claim kindly provide death certificate and letters of administration where needed)

1. Contributor Details

Name of Contributor

SSNIT Number

Gender

Scheme Member ID

Date of Birth

Ghana Card ID No

Tel Number

Email Address

GPS Address

3. Payment Details

Name on Account

Bank Name

Account Number

Branch

4. Member Declaration

I ____________________ certify that the information provided on this form is correct and complete. I further authorize the Trustee of the scheme to process and pay my benefits to the bank account details I have indicated above. I understand that I will be liable to prosecution for any false declarations.

Signature

Date

5. Employer Section

(For employer's official use only)

Name of Employer

Tel. Number

Email Address

GPS Address

Vesting Provision (Provident Fund Withdrawals)

Is the Employee vested in the Employer Contributions

YESNO

Human Resource Officer

Signature

Date

Finance Officer

Signature

Date

in the capacity as

certify that the information provided on this form is correct and

Official Use Only

Verified By

Client Service Executive

Signature

Date

No. 42 Nii Nortey Nanchii Street

Dzorwulu Accra, Ghana

P. O. Box 8952 Accra-Ghana

+233 (0) 302 780 720 | +233 (0) 302 780 765 | +233 (0) 302 780 793 | +233 (0) 302 780 452

www.standardpensions.com

Corporate Trustee. Pension Fund Administrator

Benefit Withdrawal Form

1. Contributor Details

2. Withdrawal Details

3. Payment Details

4. Member Declaration

5. Employer Section

Vesting Provision (Provident Fund Withdrawals)

Official Use Only