Form Rb1 - Claim For Retirement Benefit - Social Security Board - 2013
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1
2SOCIAL SECURITY BOARD
CLAIM FOR RETIREMENT BENEFIT
(Chapter 44, Laws of Belize)
IMPORTANT NOTICE
FOR OFFICIAL USE ONLY
/
/
Date Claim Received:
Claims for Retirement Benefit must be submitted to the
DAY
MONTH
YEAR
Social Security Board within thirteen weeks from the date
Receiving Officer:
immediately after retiring from employment or proves
/
/
Date Claim Returned:
that he/she is no longer substantially employed. Claims
DAY
MONTH
YEAR
submitted after thirteen weeks must be accompanied by
Receiving Officer:
a note stating reason for lateness.
Claim Number:
WARNING: ANY PERSON WHO KNOWINGLY MAKES ANY FALSE REPRESENTATION FOR THE PURPOSE OF OBTAINING A
BENEFIT COMMITS A CRIMINAL OFFENCE AND IS PUNISHABLE BY A FINE AND OR IMPRISONMENT.
Part I. PARTICULARS OF THE INSURED PERSON
(a) Name of Insured Person: __________________________________________________________________________
(Enter name as per Registration Card)
SURNAME
FIRST
MIDDLE
(b) Social Security No:
(c) Date of Birth:
(d) Current Age: ______________
___________________________
DAY
MONTH
YEAR
(e) Address: _______________________________________________________________________________________
HOUSE NO.
STREET
CITY/TOWN/VILLAGE
DISTRICT
_____________________________________________________
____________________________
E-MAIL ADDRESS
PHONE NUMBER
Part II. INSURED PERSON’S DECLARATION
Complete the section that applies to you
(a) I am receiving a benefit:
Yes
No
If Yes, please state Benefit Type: __________________________
(b) I am currently employed:
If employed, please state Weekly Salary: __________________________
Current Employer: _______________________________________________________________________________
Busine
ss Address: _______________________________________________________________________________
HOUSE NO.
STREET
CITY/TOWN/VILLAGE
DISTRICT
_____________________________________________________
____________________________
E-MAIL ADDRESS
PHONE NUMBER
(c) I am NOT employed:
Last Date of Employment:
___________________________________
MONTH
YEAR
DAY
(d) I authorize the Social Security Board to deposit any benefit due to me to the following financial institution:
Name of Financial Institution: ______________________________________________________________________
Branch Location: _________________________________________________________________________________
Account Number: ________________________________________________ (please attach proof of account number).
Form RB1 (July 2013)
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