NOTES:
(1)	This Form is to be completed by any person who wishes to transfer benefit to another registered Scheme
(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)

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	

SECTION II – EMPLOYER DETAILS
CURRENT EMPLOYER DETAILS	
Name of Current Employer	 	
Current Scheme Name	 	
Date of Joining Scheme (DD/MM/YYYY)	 	
PREVIOUS TRUSTEE DETAILS	
Name of Previous Employer	 	
Date of joining (DD/MM/YYYY)	 	
Date of Exiting (DD/MM/YYYY)	 	
Name of Previous Trustee/Scheme Name	 	
Scheme Type	

      Tier 2                              Tier 3  	
Member ID	 	
Name of Contact Person	 	
Contact Telephone Number	 	
Contact Email Address	 	

SECTION III – DECLARATION ON ELECTION TO TRANSFER

I…………………………………………………………………………………, certify that I am a registered Member and/my employer contributes on my 

behalf, I therefore elect that all my accrued benefits be transferred to …………………………………………………………………………………………

(Name of current scheme) and declare that to the best of our knowledge and belief, the information given on this form is complete and accurate.
										
           Full Name		Member Signature	Effective Date (DD/MM/ YY)	

Section II - Notice & Disclaimer: Anti Money Laundering/Countering Terrorist Financing

The Health Sector Scheme (HSOPS) is by law mandated to ensure that it does not participate in transactions involving the proceeds of unlawful activities or funds intended for use in terrorist activities.

HSOPS therefore requires its clients to:

a.	disclose the source of funds being paid to scheme

b.	warrant and undertake that monies being paid to the scheme are not the proceeds of unlawful activities and are not intended for use in terrorist activities;

c.	indemnify HSOPS and hold it harmless against all liability, responsibility, claims, expenses, losses or damages resulting from a breach of the warranty and undertaking in (ii); and

d.	agree to provide any information or take any action HSOPS may lawfully require in order for HSOPS to fulfil its statutory or regulatory obligations or to assist HSOPS in the event of a breach of the warranty and undertaking in (ii).

i.	By signing below, you confirm you understand and agree with the foregoing.

ii.	Source of Funds: [please state] ………………………………………………………………………………………………………………………

           Full Name		Member Signature	Effective Date (DD/MM/ YY)	

SECTION IV – 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