Claim For Survivors' Or Death Benefit Form
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2Social Security board
Part 5. Signature of the Claimant
CLAIM FOR SURVIVORS’ OR DEATH BENEFIT
I declare that the information given is true to the best of my knowledge.
(Chapter 44, Laws of Belize)
IMPORTANT NOTICE
FOR OFFICIAL USE ONLY
_______________________________
________________________
_____________________
Claims for Survivors’ Benefit must be submitted to the
/
/
Date Claim Received:
CLAIMANT’S FULL NAME IN PRINT
SIGNATURE
DAY
MONTH
YEAR
DAY
MONTH
YEAR
Social Security Board within thirteen weeks from the
Receiving Officer:
NOTE: If you are unable to sign this claim, it may be signed on your behalf by someone who should state that he or she
date of death of the deceased person. Claims submitted
has done so.
/
/
Date Claim Returned:
after thirteen weeks must be accompanied by a note
DAY
MONTH
YEAR
FOR OFFICIAL USE ONLY
stating reason for lateness. Failure to submit a claim
Receiving Officer:
Decision on Survivors’ Benefit Claim
within thirteen weeks may result in loss of benefit.
Claim Number:
WARNING: ANY PERSON WHO KNOWINGLY MAKES ANY FALSE REPRESENTATION FOR THE PURPOSE OF OBTAINING A
Four-digit Occupation Code:
[refer to Page 1 (j)]
BENEFIT COMMITS A CRIMINAL OFFENCE AND IS PUNISHABLE BY A FINE AND OR IMPRISONMENT.
Four-digit Industry Code:
[refer to Page 1 (k)]
Part 1. Particulars of the Deceased Insured Person
Decision:
Allowed
Disallowed
(a) Name of Deceased Person: ________________________________________________________________________
(Enter name as per Registration Card)
SURNAME
FIRST
MIDDLE
Monthly Pension Rate: $_____________________
OR
Amount of Grant: $________________________
(b) Social Security No:
If disallowed, state the reasons for disallowance: ___________________________________________________________
(c) Date of Birth:
(d) Date of Death:
_______________________
______________________
DAY
MONTH
YEAR
DAY
MONTH
YEAR
__________________________________________________________________________________________________
(e) Last Address: ___________________________________________________________________________________
__________________________________________________________________________________________________
HOUSE NO.
STREET
CITY/TOWN/VILLAGE
DISTRICT
__________________________________________________________________________________________________
(f) Certified Cause of Death: (i) ________________________________ (ii) __________________________________
(g) Name of Last Employer: __________________________________________________________________________
Amount of Deductions: $_____________________
SURNAME
FIRST
MIDDLE
Please indicate reasons for deductions, if any: _____________________________________________________________
(h) Business Name: _________________________________________________________________________________
__________________________________________________________________________________________________
(i) Business Address: _______________________________________________________________________________
NO.
STREET
CITY/TOWN/VILLAGE
DISTRICT
__________________________________________________________________________________________________
_____________________________
______________________________
__________________________________________________________________________________________________
EMAIL ADDRESS
PHONE NUMBER
(j) What was the deceased last occupation? ______________________________________________________________
Claim Processing
(k) What type of activity was carried on at the work place (Type of Industry)? ___________________________________
Processing Clerk: __________________________________
__________________
______/______/______
(l) Was the deceased receiving a benefit?
Yes
No If Yes, please state Benefit Type: ____________________
NAME IN PRINT
SIGNATURE
DAY
MONTH
YEAR
(m) Was the death of the deceased caused by an accident at work?
Yes
No
Part 2. Particulars of the Claimant
Verifier (FCC): ____________________________________
__________________
______/______/______
(a) The claimant is a:
NAME IN PRINT
SIGNATURE
DAY
MONTH
YEAR
Widow
Widower
Common-Law
Parent
Guardian
(b) Name: ________________________________________________________________________________________
(Enter name as per Registration Card)
SURNAME
FIRST
MIDDLE
Authorizer (AA/ADMIN): ____________________________
__________________
______/______/______
(c) Social Security No:
(d) Date of Birth:
_________________________
NAME IN PRINT
SIGNATURE
DAY
MONTH
YEAR
DAY
MONTH
YEAR
(e) Last Address: ___________________________________________________________________________________
Relevant Notes:
__________________________________________________________________________________
HOUSE NO.
STREET
CITY/TOWN/VILLAGE
DISTRICT
_____________________________
_____________________________
__________________________________________________________________________________________________
EMAIL ADDRESS
PHONE NUMBER
__________________________________________________________________________________________________
(f) For Guardians, state relationship to child or children:
Grandparent(s)
Uncle
Aunt
Sister
[Proceed to Part 3 (ix) from a to d and also complete Part 4]
__________________________________________________________________________________________________
)
Brother
Other (Specify:__________________
SVB1 Form (Revised August 2012)
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