Disability Appeal Form For South African Local Authorities Pension Fund Members Page 5

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If no, please explain why not.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please explain in your own words why you feel these changes are not sufficient to enable you to
return to work either in your own or an alternate occupation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DECLARATION
I hereby declare and confirm that the answers given by me and the information disclosed in this form are
complete in all respects, are both true and correct (whether in my handwriting or not) and that no material
information has been withheld nor has any relevant information regarding my physical and/or mental
health been omitted, either intentionally or negligently.
I further declare that I am the deponent mentioned above and acknowledge that I know and understand
the contents of this document.
_____________________________________
Signature or Mark of Claimant
SIGNED AND AFFIRMED AT: ____________________________________
On this _________ day of _________________________________20________
Appeal Application Form
Page 5 of 5
Strictly Private and Confidential

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