Certificate Of Life And Receipt Of Pension
Download a blank fillable Certificate Of Life And Receipt Of Pension in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Certificate Of Life And Receipt Of Pension with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1DOMINICA SOCIAL SECURITY
CERTIFICATE OF LIFE AND RECEIPT OF PENSION
To: Mr./Mrs./Ms. ____________________________
Address:
_____________________________
_____________________________
_____________________________
Dear Sir/Madam,
In keeping with Section 22(2) of the Social Security (Claims and Payments) Regulations, persons in
receipt of benefit are required—from time to time—to furnish documented evidence that they are alive
and that the conditions governing their continued entitlement to such benefit are fulfilled. Accordingly,
you are asked to complete and return this form to the office of the Dominica Social Security not later
than …………………………………………………………… .
Failure to return this form within the specified time will result in suspension of the benefit until such
evidence is received. It must be noted, further, that the right to any sum payable shall be lost where it
is not obtained within six months of the date on which such sum is receivable (as per Section 19 (1) of
the Claims and Payments Regulations).
Name of Pensioner:
_____________________________
Pension Type: ___________________
S.S. No. /__/__/__/__/__/__/__/__/__/__/__/__/__/
Claim No. _______________________
Current Address:
______________________________________________________________
(If different from above)
I certify that I am alive and the above is true and correct.
____________________________________
______/_______/________
Signature or Mark (x) of Pensioner
Date
N.B:
The Witness, who must not be related to you, could be either of the following persons:
Justice of Peace; Notary Public; Lawyer; Police Officer (Sergeant or above); Ordained Minister
of Religion; Doctor; Family Nurse Practitioner; School Principal; Licensed Surveyor; Bank or
Credit Union Personnel; Social Security Officer. (In the case of persons residing overseas, the
document must be notarized prior to being submitted to the DSS office).
DECLARATION OF WITNESS
I have read the contents of this form and certify that the above person signed or made his/her mark “x”
in my presence.
_____________________________________
______________________________________
Signature of Witness
Occupation/Position/Title of Witness
_____________________________________
_____/_______/_________
Name of Witness in Block Letters
Date & Stamp if available
ADVERTISEMENT
0 votes
Related Articles
Related forms
Certification Of Service And Final Salary - Retirement Form - Division Of Pensions And Benefits
Legal
Certificate To Amend Application For Certificate Of Registration For A Foreign Limited Liability Company Form - Department Of Consumer And Regulatory Affairs, District Of Columbia
Legal
Related Categories
Parent category: Legal