NOTES:
(1)	This Form is to be completed by any person who wishes to claim for payment of accrued benefits
(2)	Please use BLOCK LETTERS for completion of this Form
(3)	Please write “N/A” if not applicable
(4)	Attach a photocopy of any valid National ID (Voters ID, Passport, Driver’s license, Ghana Card)
(5)	Attach all relevant documents under section III based on the grounds for claiming accrued benefit

The information given in this Form can be used by the Approved Trustee concerned and the National Pensions Regulatory Authority (“the Authority”) in activities relating to the processing of the claim and may be disclosed to other parties for such purposes.	AFFIX RECENT PASSPORT (INDICATE NAME BEHIND PICTURE AND APPEND	

SECTION I - DETAILS OF CLAIMANT
Surname *		
First Name *		
Other Name		
Date of Birth *	D	D	M	M	Y	Y	Y	Y	Age		Sex	

Male                    Female	
Select Appropriate ID *	

Passport                    Voter ID                          Drivers License                     Ghana Card	
ID Number *										Staff ID Number *
 									
SSNIT Number *																						
HSOPS Scheme ID Number*																				
Mobile Number *																						
Email Address *																						
Postal Address *																						
Residential Address *																					
Closest Landmark																					
Place of Work *																					
Last Grade																					
Date of Joining Scheme	D	D	M	M	Y	Y	Y	Y	Date of Retirment *	D	D	M	M	Y	Y	Y	Y	

SECTION II – GROUND FOR BENEFIT REQUEST

Grounds for claiming accrued benefits: (Please tick ‘√’ one box) *

I. Compulsory Retirement (scheme member reaches the retirement age of 60 years)		
   II. Voluntary Retirement		

   SECTION III - DOCUMENTS ENCLOSED
You must attach the following documents in respect of the claim for payment on grounds of (Please tick ‘√’ the appropriate box)

a.	Compulsory Retirement (60 years)

i.	A copy of ID card for verification of your identity	
ii.	Retirement notification letter from employer	
iii.	SSNIT biometric ID	
iv.	SSNIT Payment Advice Slip	

b.	Voluntary Retirement
Option (1) Scheme member reaches the age of 55 and has applied for voluntary retirement.
	
i.	A copy of ID card for verification of your identity	
ii.	The original copy of a statutory declaration on early 
iii.	retirement (affidavit sworn by member)	
iv.	SSNIT biometric ID	
v.	SSNIT Payment Advice Slip	

Option (2) Scheme member reaches the age of 50 and has permanently ceased all 
employments/self-employment

i.	A copy of ID card for verification of your identity	
ii.	The original copy of a statutory declaration on cessation of employment or certificate of unemployment from labor Office	
iii.	SSNIT biometric ID	
iv.	SSNIT Payment Advice Slip	

SECTION IV - PAYMENT INSTRUCTION

Account Details- Member Benefits
a.	Ensure that the bank account details supplied are in respect of your own account number.
b.	Note however that the value that will be paid into the account stated below will be less any outstanding bank charges relating to your payment.
c.	Do make DOUBLE SURE that all account information is correct to prevent undue delays in the settlement of your benefit

Account Name*

Account Number*

Bank Name *                                                                                                  Branch Name

 SECTION V - MEMBER DECLARATION

I.	I completed this form in my own handwriting and.

a.	I declare and certify that to the best of my knowledge and belief, the information given in this
b.	Form and its attachment(s) are correct and complete.

II.	I am duly informed and to my full understanding that I will be liable to prosecution for any FALSE
information or declaration herein or hereafter made to the Scheme.

Signature (MEMBER) *                                                                           Signed Date (DD/MM/YYYY)

III.	This form was completed on my behalf by another person and;

a.	I declare and certify that to the best of my knowledge and belief, the information given in this has been duly explained to my full understanding and satisfaction.

b.	I am duly informed and to my full understanding that I will be liable to prosecution for any FALSE information or declaration herein or hereafter made to the Scheme.

     Thumb Print (MEMBER)
	
Thumb Date 	D	D	M	M	Y	Y	Y	Y	

SECTION VI - JURAT

If the Applicant cannot read and write English, the following Jurat should be signed
I certify that this Application Form, before being signed by the Applicant was first audibly, clearly and distinctly read over and explained to him/her in my presence and hearing and the said Applicant appeared perfectly to have understood same before making his/her mark hereto.
DETAILS OF WITNESS
Surname *		
First Name *		
Other Name		
Date of Birth *	D	D	M	M	Y	Y	Y	Y	Age		Sex	

Male                    Female	
Select Appropriate ID *	

Passport                Voter ID                    Drivers License                  Ghana Card	
ID Number *													 									
Signature *		Date *	D	D	M	M	Y	Y	Y	Y