NOTES:
(1)	This Form is to be completed by non-Ghanaians who wishes to permanently emigrate to their home country.
(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)
(5)	Attach all relevant documents under section III

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 Exiting Scheme *	D	D	M	M	Y	Y	Y	Y	

RESIDENTIAL ADDRESS/LOCATION (GHANA)	RESIDENTIAL ADDRESS/LOCATION (ABROAD/OVER SEAS)	
House Number									House Number										
Street Name									Street Name										
Town/City									Town/City										
Country									Country										
Landmark (eg Near/Opposite a School/Church/Palace/etc)	Landmark (eg Near/Opposite a School/Church/Palace/etc)	

SECTION II – GROUND FOR BENEFIT REQUEST

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

I. Permanent Emigration (scheme member relocating) 		

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

i. A copy of your ID card for verification of your identity	
ii. A copy of the immigration visa/foreign passport/ Entry Permit (for Ghanaian Residents)/others etc.                                                       (Please specify type of other documents) giving the member the permission to reside permanently or for an indefinite period in a place outside Ghana.
	
iii. The original copy of the statutory declaration on permanent emigration 	
iv.  SSNIT Payment Advice Slip on permanent emigration 	
v. SSNIT biometric ID	

SECTION IV - PAYMENT INSTRUCTION

Account Details- Member Benefits
a.	Ensure that the bank account details supplied are in respect of your own account n umber.
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

d.	Additional overseas bank details (provide for transfer outside Ghana)

Bank’s Country                                                  IBAN Details                                                                       Bank’s Swift Code

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