Mm Engineering

ENGINEERING INDUSTRIES PENSION FUND /

METAL INDUSTRIES PROVIDENT FUND

Private Bag X11

Marshalltown, 2107 /

** ******** ******, *********** ***

Johannesburg, 2000

Call Centre No: 086-***-****

Fax No: (011-***-****

PAYMENT OF SURPLUS BENEFITS

Website: www.mibfa.co.za

First Names

Surname

Address

Postal Code

Tel No. (H) Cell No. Tel No. (W) Fax No.

Date of Birth DD MM YY Maiden Name

Identity Number

(Certified copy of Identity Document

must be attached)

Old Reference Book No.

Previous Passport/

Identity Numbers

(Certified copies must be attached)

Name of last employer in Metal Industries

Date of leaving the last Employer DD MM YY

Date of payment of benefit from

DD MM YY

Metal Industries (approximate)

Name of CURRENT Employer

Date DD MM YY

SIGNATURE OR MARK OF APPLICANT

PLEASE NOTE: Copies of the following documents would assist in speeding up the processing of

your application:

• Annual benefit statement you received from the Funds

• Correspondence relating to any previous benefit payment received from the Funds.

Once the Surplus Scheme has been approved by the Financial Services Board, MIBFA will require you to

supply a certified Bank Mandate form obtained from your Bank in order to pay any benefit due to you.

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