Continuing Eligibility To Receive A Benefit Form - Nib Page 2
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1
2S
B
S
& I
D
B
S
V
URVIVORS
ENEFIT
POUSE
NDUSTRIAL
EATH
ENEFIT
POUSE
ERIFICATION
1. Have you remarried?
Yes
No
2. Employment Status:
Employed
Self-Employed
Unemployed
3. If Employed/Self-employed, how much do you earn Weekly: $__________/ Monthly: $__________
Employer’s Name: ________________________ Address: _________________
Tel: ______________
4. Are you an invalid?
Yes
No
5. Do you have custody of any dependent or orphan children?
Yes
No
6. If “Yes”, indicate below their names and whether they’re attending school full-time:
Attending
Date of
Living
Supported
school
Name of
Child’s Full Name
birth
with you? by you? full-time?
School
dd
mm
yy
yes no yes
no yes
no
S
B
P
/I
D
P
V
URVIVORS
ENEFIT
ARENT
NDUSTRIAL
EATH
ARENT
ERIFICATION
1. Employment Status:
Employed
Self-Employed
Unemployed
2. If Employed/Self-employed, how much do you earn Weekly: $__________/ Monthly: $__________
Employer’s Name: _________________ Address: _____________________ Tel: _________________
3. Are you an invalid
Yes
No
D
S
A
ECLARATION BY
ANCTIONED
UTHORITY
Office Seal
Document used to identify Pensioner:________________________#_______________
or
office stamp here
“This is to certify that __________________________________ is alive and has been
interviewed by me on this______ day of ________________________ 20_____”
Signature
Full Name (Please Print)
Position
D
P
ECLARATION BY
ENSIONER
To be signed in the presence of the sanctioned authority
“I__________________________________ do, hereby, declare that all of the information supplied by me on
this form is true to the best of my knowledge and belief.”
Signature or Mark of Pensioner
Witness to Mark
Date
NOTE: Any person who, for the purpose of obtaining a Benefit under Section 49(5) Chapter 350 Statute Laws of The
Bahamas, either for himself or for some other person, knowingly makes false statements or submits false documents,
shall be liable to a fine not exceeding $2,500 or to imprisonment for up to twelve months or both.
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