Form Ui-25 - Application Dependant Partner Benefits - Unemployment Insurance

UI-2.5

UNEMPLOYMENT INSURANCE ACT 63 OF 2001

APPLICATION FOR DEPENDANT’S BENEFITS BY SURVIVING SPOUSE OR LIFE PARTNER IN TERMS OF SECTION 31(1) Read with Regulation 7(1)

A.

PARTICULARS OF DECEASED CONTRIBUTOR:

13 Digit Bar-Coded Identity Document/Passport Number

Date of Birth (dd/mm/yy)

Gender

Male

5

Female

0

First Names

Surname

Date of Death

Last Residential Address

Code

Details of previous application

a)

Name and ID No under which deceased applied:

b)

Date of Application: ______/____/_____

c)

Office of application:

B.

PARTICULARS OF SURVIVING SPOUSE OR LIFE PARTNER: (NOTE: In the case of a surviving spouse if there is not a marriage certificate recognised as valid in terms of any law relating to marriage in force in the Republic of South Africa,

supplementary documents required by the Department regarding the circumstances of the matter should be attached)

13 Digit Bar-Coded Identity Document/Passport Number

Date of Birth (dd/mm/yy)

Gender

Male

5

Female

0

First Names

Surname

Postal Address

Tel No

Code

Residential Address

Cell No

Code

Occupation

Occ. Code

E-Mail Address

Method of Payment

Use the UI-2.8 form for Banking Details

PAYPOINT

CHEQUE

BANK TRANSFER

OTHER

I declare that I am the only surviving spouse or life partner or one of ________ surviving spouses of the abovementioned deceased contributor, that I was not divorced from him/her and that information given in this document is true and correct. I understand that

it is an offence to make a false statement.

SIGNATURE OF SURVIVING SPOUSE OR LIFE PARTNER: ____________________________________

DATE: _____/_____/______

OFFICE STAMP

FOR OFFICIAL USE ONLY

Signature of Official

DOCUMENTS/INFORMATION SUBMITTED

Claim approved from: ______________________

1.

UI-19 (If Applicable)

8.

SARS Number: ________________

Application refused in terms of: ______________________

2.

Certified Copy of ID (Deceased & Dependant)

9.

Telephonic Verification

REMUNERATION/SALARY

Claims officer (Please Print): _________________________________________

3.

Payslips/Database

Contact Person: ____________________

Gross pay

Payment Frequency

4.

Affidavit from Life Partner

Designation: __________________________

(before deductions)

(PW or PM)

Signature: ________________________________

5.

Proof of banking details – UI-2.8

Tel. No.: ____________________________

6.

Marriage certificate or certified copy

Date: _______________

7.

Certified Copy of ONE of the following documents

(i)

Death certificate

(ii)

Post-mortem certificate

(iii) Burial order relating to the death of such

contributor