Form B.75b - Continuing Eligibility To Receive A Benefit - Nib Page 2
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2Survivors Benefit Spouse & Industrial Death Benefit Spouse Verification
1. Have you remarried?
Yes
No
2. Are you:
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 /orphan children? Yes
No
6. If “Yes”, indicate 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
Industrial Death Parent/Survivors Benefit Parent Verification
1. Are you:
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
DECLARATION BY SANCTIONED AUTHORITY
Document used to identify Pensioner:________________________#________________
Office Seal
or
“This is to certify that __________________________________ is alive and has been
stamp here
interviewed by me on this______ day of ________________________ 20_____”
Signature
Full Name (Please Print)
Position
DECLARATION BY PENSIONER
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 of Mark of Pensioner
Witness to Mark
Date
NOTE: A “SANCTIONED AUTHORITY”
is an Officer of the National Insurance Board; Counsel or Attorney of the
Supreme Court; a Public Officer above the rank of Assistance Head of Department; an ordained Minister of Religion; a Bank
Manager; Magistrate; or Justice of the Peace, who is not a member of the Pensioner’s immediate family. In the case of Pensioners
who reside outside of the country, a sanctioned authority may also be a Notary Public; a Lawyer, or a Chief of Police.
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