No. 1.0 August 2014
ANNEXURE A OF THE DEATH CLAIMS FORM
DECLARATION OF FINANCIAL INDEPENDENCE
Important
▪▪ Please complete this Annexure if you are a major and you were not financially supported by the deceased member
at date of death.
Information
Deceased member’s full name
Date of birth
D D M M Y
Y
Y Y
I, (full name and surname)
ID number (passport number if foreign national)
Occupation
Daytime landline number
Mobile
Email
Relationship to the deceased member
Declare that:
▪▪ I was not financially dependent on the member at the time of his/her death.
▪▪ Where applicable, even though I (and my child(ren) if applicable) was/were living in the same household as the deceased member,
I (and my child(ren) if applicable) did not receive financial support from him/her.
▪▪ I would not have become financially dependent on the member had he/she not died.
▪▪ In my opinion the following persons were most likely financially dependent on the member at the time of his/her death:
Name and surname
Name and surname
Name and surname
Name and surname
Name and surname
I am not aware of any other person(s) who may have been financially dependent on the member at the time of his/her death.
Please provide any additional information which the trustees should be aware of in order to allocate the benefit fairly.
Declaration
I, (full name and surname)
declare under oath that
the information in this form is, to the best of my knowledge, true and correct.
Signed at
on the day of c
c
y
y
Signature
Where to submit the completed form:
Please fax the completed Annexure to the Client Service Centre at 0860 000 655 or +27(0)21 415 2492, email it to
[email protected] or post it to PO Box 51605, V&A Waterfront, Cape Town, 8002
Death Claims Form - Annexure A
Allan Gray Proprietary Limited is an authorised financial services
1 of 1