Confinement Certificate/maternity Grant Application Form printable pdf download

Certificate of Confinement

I certify that on the ________ day of _______________ 20 _____, I assisted at the confinement of Miss/Mrs.

______________________________________ Social Security Number ____________________. This confinement

took place at the ________________________________ *on behalf of the services of this Government’s institution.

Full name of Registered Medical practitioner/Midwife ______________________________________________

Address___________________________________________________________________________________

Signature __________________________________________ Telephone Number _____________________

*(Delete this sentence if inapplicable)

NOTE: Please read carefully before submitting to Social Security Office

1. The insured person must have paid amounts due to the Government Institution to qualify for the full grant.

*2. Where the claim is made by a man on behalf of his spouse he is required to present:

(i)

the birth certificate of the child

(ii)

marriage certificate in support of marriage unions or

(iii)

declaration made under oath before a Justice of Peace or Notary Public in support of common-law unions

between the spouses of not less than three (3) years

(iv)

any other supporting documents requested by the Director should it be deemed necessary.

EMPLOYEE’S CLAIM FOR MATERNITY GRANT

FOR OFFICIAL USE

Claim No.

Insured woman already in receipt of weekly maternity

Benefits need not send this form to her employer (s)

Date Rec’d

Clerk’s initial

Claimant’s Full Name ____________________________________ S.S # _____________________________

Home Address __________________________________________ Date of Birth _______________________

Mailing Address _________________________________________ Tel. ______________________________

I hereby claim maternity grant on behalf of myself/*my spouse *See 2 above

(Delete as appropriate)

___________________________________________________

____________________________________

(insert spouse’s name)

(SS# of spouse if applicable)

Signature or Mark ‘X’ of Claimant _____________________________ Date ___________________________

Signature of Witness to Mark ‘X’ ______________________________ Date ___________________________

Certification from Accounts Department, Princess Margaret Hospital or other relevant Government Institution

I certify that the above mentioned person has settled all amounts due in respect of the above confinement.

I certify that the above mentioned person is indebted to this institution in the sum of $ ____________

_______________________________

__________________________________

____________________

SIGNATURE

FULL NAME

DATE & STAMP

Confinement Certificate/maternity Grant Application Form

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