THE NATIONAL INSURANCE BOARD NI 82
RETIREMENT BENEFIT APPLICATION (FOR OFFICIAL USE)
CLAIM NO:
(PLEASE USE BLOCK/CAPITALS)
Please read the notes at the back of this form CAREFULLY. SERVICE CENTRE CODE:
NOTE: This application must be submitted not later than 12 months from the date of Retirement.
SECTION "A" - TO BE COMPLETED BY APPLICANT
1. NAME:
SURNAME OTHER NAME(S)
2. HOME
ADDRESS:
(STREET)
3. *POSTAL (CITY/DISTRICT/COUNTY)
ADDRESS (if
different
(STREET)
from above):
(CITY/DISTRICT/COUNTY)
4. NATIONAL 5. DATE OF
6. GENDER: MALE FEMALE
INSURANCE NO.: BIRTH:
YYYY MM DD
7. TELEPHONE NUMBERS: -- -- --
(HOME) (OFFICE/WORK) (CELLULAR)
8. MARITAL STATUS: SINGLE MARRIED WIDOWED DIVORCED
9. STATE MAIDEN NAME
(Where applicable):
SURNAME
10. LAST
OCCUPATION:
11. NAME OF
LAST EMPLOYER:
12. LAST EMPLOYER
REGISTRATION NO:
(If known)
13. EMPLOYMENT RECORD FROM 10 APRIL, 1972. (Please use additional sheets of paper if more space is required.)
NAME OF EMPLOYER ADDRESS OF EMPLOYER TYPE OF EMPLOYMENT PERIOD OF
TEMPORARY/CASUAL/ EMPLOYMENT
PERMANENT
14. DID YOU WORK OR LIVE IN CANADA OR WORKED IN ANY OF THE CARICOM COUNTRIES? YES NO
If "YES", please provide: (i) SOCIAL SECURITY NO.
(ii) COUNTRY:
15. LAST DATE OF EMPLOYMENT:
YYYY MM DD
N.B. This should include pre-retirement leave/vacation leave. (See pg. 4 for details)
16. HAVE YOU EVER APPLIED FOR A RETIREMENT BENEFIT? YES NO
If "YES", state Service Centre:
*EXAMPLE: Light Pole No. 8, Southern Main Road, Couva OR Near Bertie's Parlour, Industry Lane, Belmont.
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SECTION "A" - TO BE COMPLETED BY APPLICANT (CONT'D)
17. ARE YOU IN RECEIPT OF ANY BENEFIT LISTED BELOW?
(a) INVALIDITY YES NO
(b) SICKNESS YES NO
YES NO
(c) EMPLOYMENT INJURY
18. HAVE YOU PAID VOLUNTARY CONTRIBUTIONS? YES NO
19. PLEASE INDICATE THE METHOD OF PAYMENT OF BENEFIT:
MAIL TO: POSTAL ADDRESS DEPOSIT TO: FINANCIAL INSTITUTION
(If method of payment is "FINANCIAL INSTITUTION", complete below).
FINANCIAL INFORMATION
(If method of payment is "FINANCIAL INSTITUTION", complete below).
The NIBTT considers the foregoing information as instructions from you regarding the deposit of your benefit payment to the
financial institution of your choice.
The NIBTT is not liable for any payment issued to an inaccurate financial institution or account based on these instructions.
NAME OF FINANCIAL
INSTITUTION:
ADDRESS:
(STREET)
(CITY/DISTRICT/COUNTY)
ACCOUNT NUMBER:
20. IS THIS ACCOUNT A JOINT ACCOUNT? YES NO
21. IF "YES", PLEASE STATE THE NAME(S) AND ADDRESSES OF JOINT ACCOUNT HOLDER(S).
NAME:
SURNAME OTHER NAME(S)
ADDRESS:
(STREET)
(CITY/DISTRICT/COUNTY)
NAME:
SURNAME OTHER NAME(S)
ADDRESS:
(STREET)
(CITY/DISTRICT/COUNTY)
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3/NI 82
DECLARATION
I declare that to the best of my knowledge and belief the information given by me is true and correct and I am aware that if
there is any statement in this declaration which is false in fact or which I know or believe to be false or do not believe to be
true, I am liable on summary conviction to a fine of three thousand dollars ($3,000.00) and to imprisonment for two years
in accordance with Sect 33, NI Act Chap 32:01.
DATE:
SIGNATURE OR MARK OF APPLICANT YYYY MM DD
PARTICULARS OF WITNESS TO MARK (Where Claimant Cannot Sign)
NAME:
SURNAME OTHER NAME(S)
ADDRESS:
PASSPORT
(STREET)
VALID IDENTIFICATION: DRIVER'S PERMIT
(Tick appropriate box)
(CITY/DISTRICT/COUNTY) ELECTORAL I.D.
OCCUPATION: NUMBER:
DATE:
SIGNATURE OF WITNESS YYYY MM DD
SECTION "B" - TO BE COMPLETED BY LAST EMPLOYER (SEE NOTE NO. 8 ON PAGE 5)
I certify that
SURNAME OTHER NAME(S)
whose date of birth is retired from our Employment with effect from
YYYY MM DD YYYY MM DD
TICK APPROPRIATE BOX:
HAS BEEN RE-EMPLOYED WITH EFFECT FROM
YYYY MM DD
HAS NOT BEEN RE-EMPLOYED AFTER
YYYY MM DD
I declare that to the best of my knowledge and belief the information given by me is true and correct and I am aware that if
there is any statement in this declaration which is false in fact or which I know or believe to be false or do not believe to be
true, I am liable on summary conviction to a fine of three thousand dollars ($3,000.00) and to imprisonment for two years
in accordance with Sect 33, NI Act Chap 32:01.
NAME:
SURNAME OTHER NAME(S)
POSITION:
COMPANY
STAMP
(If any) DATE:
SIGNATURE: YYYY MM DD
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SECTION "C" - FOR OFFICIAL USE
APPLICATION RECEIVED BY:
NAME:
SURNAME OTHER NAME(S)
SERVICE
CENTRE DATE:
SIGNATURE OF SERVICE CENTRE STAFF
STAMP
YYYY MM DD
PART "I" - CUSTOMER SERVICE REPRESENTATIVE
1. NAME, N.I. NO. AND DATE OF BIRTH CONFIRMED AND UPDATED (IF NECESSARY) ON I.A. SYSTEM YES NO
2. REGISTRATION RECORD COMPLETED? (If "NO" complete forms NI 165/NI 182 as applicable) YES NO
3. CHECK FOR DUPLICATE REGISTRATION (SIRF file included)? (Record Results on Minute Sheet) YES NO
4. CLAIM HISTORY VIEWED? YES NO
(If yes, record findings here.)
(Use minute sheet if this
space is inadequate.)
5. APPLICATION COMPLETED AND ACCEPTED FOR PROCESSING? YES NO
6. APPLICATION RECORDED? (Print and attach Claim Profile) YES NO
7. OUTSTANDING CONTRIBUTION RECORDED? (Print and attach Audit Report) YES NO
8. APPLICATION PROCESSED? YES NO
DATE:
CUSTOMER SERVICE REPRESENTATIVE YYYY MM DD
PART II - MANAGER/SUPERVISOR/CLERICAL OFFICER II
1. DETAILS OF CLAIM PROFILE VERIFIED? YES NO
2. CONTRIBUTION AUDIT REPORT VERIFIED? YES NO
3. CONTRIBUTIONS TRANSFERRED? YES NO
4. CLAIM AUTHORIZED/DISALLOWED? YES NO
DATE:
MANAGER/SUPERVISOR/CLERICAL OFFICER II YYYY MM DD
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RETURN OF BENEFIT APPLICATION
1. Use BLOCK/CAPITALS to complete this Form.
2. Retirement Benefit is payable from age 60 (provided that you are no longer in Insurable Employment)
OR from age 65 whether employed or not. Your application must be submitted not later than 12
months from the Date of Retirement.
3. There are TWO types of Retirement Benefit:
(a) Retirement Pension, OR (b) Retirement Grant, if you do not qualify for the Pension.
Leaflets available at your Service Centre will provide details on these Benefits.
4. For item 15, the "Last Date Of Employment", relates to the last date on which you were paid by your
Employer.
5. For item 18, Voluntary Contributions are paid by an insured person who is unemployed and wishes to
maintain his contribution record during periods of unemployment.
6. Your completed Form MUST be accompanied by a CERTIFIED COPY of your Birth
Certificate/Affidavit if necessary. In the case of a married Female, a CERTIFIED COPY of your
Marriage Certificate MUST ALSO be submitted.
7. Your Retirement Pension Payments will be sent to a Financial Institution of your choice every month.
Note however, a Form NI 65 - "Life Certificate" MUST be completed and submitted as required by the
Board for payments to continue. These certificates are available from any Service Centre.
8. SECTION 'B' is to be completed by last employer for persons who were no longer in insurable
employment prior to age 65.
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