Form Ui-2.4 - Application For Adoption Benefits
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1UI-2.4
UNEMPLOYMENT INSURANCE ACT 63 OF 2001
APPLICATION FOR ADOPTION BENEFITS IN TERMS OF SECTION 28(1
)
Read with Regulation 6(1)
13 Digit Bar-Coded Identity Document/Passport Number
Id no of adopted child
Date of Birth (dd/mm/yy)
Gender
Male
5
Female
0
First Names
Surname
Postal Address
Code /Telephone No
Code
Residential Address
Cell No
Code
Occupation
Occ. Code
E-Mail Address
Fax Number
Method of Payment
Use the UI-2.8 form for Banking Details
PAYPOINT
CHEQUE
BANK TRANSFER
OTHER
Details of previous application
a) Name and ID No under which you applied:
b)
Date of Application: ____/___/____
c)
Office of application:
ARE YOU STILL EMPLOYED
YES
NO
SOURCES OF OTHER INCOME (mark X were applicable)
NB:
IF YOU ARE STILL EMPLOYED, FORM UI-2.7 MUST ALSO BE COMPLETED
1.
Monthly Pension from State (Excluding Disability grant)
2.
Benefit from Compensation Fund for temporary or total disablement
DATE OF COMMENCEMENT OF ADOPTION LEAVE: _____/_____/______
3.
Benefits from an Unemployment Fund established by a bargaining or statutory council
IF YOU HAVE RETURNED TO WORK, STATE DATE: _____/_____/______
4.
NONE
IMPORTANT: READ THIS SECTION BELOW
If applicable mark X on 1-4:
When did you begin to receive this income? ____________________
If your application is successful then the claims officer will authorise the payment of benefits. You must also
inform the claims officer as soon as you resume work. I declare the above information is true and correct. I
understand that it is an offence to make a false statement.
Do you continue to receive this income? _____________
If you no longer receive this income when did it come to an end? _________________________________
SIGNATURE OF APPLICANT: _________________________
DATE: ________
OFFICE STAMP
FOR OFFICIAL USE ONLY
Signature of Official
DOCUMENTS/INFORMATION SUBMITTED
Claim approved from: ______________________
1.
UI-19 (If Applicable)
8.
Copy of Adoption Order
Application refused in terms of: ______________________
2.
Certified Copy of ID
9.
SARS Number: ____________________
REMUNERATION/SALARY
Claims officer (Please Print): _________________________________________
3.
Payslips
10.
Other (Specify) ____________________
Gross pay
Payment Frequency
4.
Affidavit – Period Spent caring for child
11.
Telephonic Verification
(before deductions)
(PW or PM)
Signature: ________________________________
5.
Proof of banking details - UI-2.8
Contact Person
6.
UI-2.7 (If applicable)
Designation:
Date: _______________
7.
Birth certificate of Child
Tel. No.:
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