NATIONAL SOCIAL SECURITY FUND INSSF BENEFITS CLAIM FORM PLEASE READ THROUGH BEFORE COMPLETING THIS FORM. USE BLOCK LETTERS THROUGHOUT SECTION 1: BENEFIT CLAIM SPECIFICATION Please ick the appropriate box forthe type of Benefit Clam you would tke to submit (1)Aoe Benefit 58 years (2Withraal Benefit at 50 years and out of employment. 6) Emigration Gant (Leming Uganda Permanent) fl (4ithraval Beneft folowing exeped emioyment) (©)imaity Benefit ncapactated) I (@Suviors Benet SECTION 2: MEMBER DETAILS (1) Surname: (2) Other names: (G)NSSE Number (Other NSSF number -fappicable- please indicate inthe space after the boxes) (4) Nationality {6) Nationa Identification Numbecien dentification No, (6) Dato of Bit fh (7) Place of Bit (alge ee (Coun ee Conny eee eee (6 Distt, 8) Telephone number, (9) Email ¢F any jee H(i) PO Soe aan onan (1) Curent Residential Address (Vilage sft) Sub County, 4) County vd) Distt, SECTION 3: EMPLOYMENT RECORD Lt all your employers starting with the MOST curent employer (ull name of organization) Continue on atonal pain sheet of plain paper it necessary SECTION 4: FOR CLAIMANTS OF SURVIVORS BENEFITS ONLY Beneficiary Sumame, Beneficiary other Names, National Menifcaion Number / Alen identification Number: (12) Curent Residential Address (Vilage... e {b) County, — — read) DIS . Beneficiary’s Date of Birt 0 ry (14) Beneficiany’s Place o Birth (aVilage (b) County, (o) Distt, (15) Telephone number... = eee (0) rl ee(17) Gender Male Female (18) Beneficiay/s Martal Status... (19) Beneficay’s Father's Full NaMeS nef) Beneficiary’ Mother's Full Names... = (21) Relationship with the DaCe3S2 sr nnnnnnnnnnnn(®2) Daosased Date of Death, SECTION 5A: ELECTRONICY BANK FUNDS TRANSFER SECTION 5: MODE OF PAYMENT Bank I Mobile Money. Others (epecity) ‘SECTION 5A: ELECTRONIC/ BANK FUNDS TRANSFER CLAIMANTS WITH FOREIGN ACCOUNTS: | oonsent that NSSF pays mein foreign curency based on the prevaing spot exchange rate NSSF's bank lof... SECTION 5B: MOBILE MONEY (For Benefits up-to @ maximum allowed by the lav) “Tena suo conomions yng tis fm, eet peste feng. {etch sss al se seyret isco rl SE lk bert ays at a a tt "atin sods ESE a ease ase th amt oN ree a rasan soy se ome tl oso Tak YES tl net pon elk lass Campos De, apo Mates Dane an re Ses ss ae et Ms poe Tt SE a ‘eee ate por settee tareson iene Sash dakar ates et pg ua he PM past a eS? ‘fete as cre eo ant PR pasts ah as ca 7. Eres fo dh ee care tel ey a ‘bbe tory ach cn sg aya corre eel ono eo ute ae oa aE fa aH aaa ese cd oat crc oe ev pe Th HS sh poe ea angen aus and ay ren cz al te nade a ea ha SE shlebo ‘usb nese cmp de as ane ma scr ade a gen taste 0 Ven Ps aers nae a ety he am tan Stop, rey oy octaegt as SECTION 6: FINGER PRINTS. SECTION 6A: RIGHT HAND FINGER PRINTS (Please indicate by ink the Finger print) LEFT HAND THUMBPRINT LEFT HAND POINTER RIGHT HAND THUMBPRINT RIGHT HAND POINTER. (Tobe sgnadin the presence of an NSSF Over) Claimant's Signature ee Date DDIM nnn Ti (12-hour fra. (@)8ysgnng accept hat have ead the TCs an hereby ndcate ny consent.) For persons with salty an haze who canna sgn o present ater traceable pial identi, the NSS officer shall consent to have oficial authenticate. ‘SECTION 7: DECLARATION BY NSSF STAFF a ete ge ioe conto tia ‘thumb-prnts and photograph atached belong tothe claimant and tha the claimant has been identfied as per documentation provided, Offices Sight nnn DDIMMNY nnn (12 ROW FEM