Form Fg.1 - Claim For Funeral Grant - Social Security Board - 2013
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1
2SOCIAL SECURITY BOARD
ClAIm FOR FUNERAl GRANT
(Chapter 44, laws of Belize)
IMPORTANT NOTICE
FOR OFFICIAL USE ONLY
Claims for Funeral Grant must be submitted to the
/
/
Date Claim Received:
DAY
mONTH
YEAR
Social Security Board within six months from the date
Receiving Offi cer:
of death of the deceased person. Claims submitted aft er
/
/
Date Claim Returned:
six months must be accompanied by a note stating reason
DAY
mONTH
YEAR
for lateness. *Claims received aft er twelve months are
Receiving Offi cer:
not payable.
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 DECEASED PERSON
(a) Name of Deceased Person: _________________________________________________________________________
(Enter name as per Registration Card)
SURNAmE
FIRST
mIDDlE
(b) Social Security No:
(c) Date of Birth:
_______ /_______ / _______
DAY
mONTH
YEAR
(d) Date of Death:
(e) Occupation: _______________________________________
_______ /_______ / _______
DAY
mONTH
YEAR
(f) Certifi ed Cause of Death: (i) ________________________________________________________________________
(ii) _______________________________________________________________________
(g) Name of Last Employer/Business Name: _______________________________________________________________
(h) Business Address: ________________________________________________________________________________
NO.
STREET
CITY/TOWN/VIllAGE
DISTRICT
__________________________________
______________________________
E-mAIl ADDRESS
PHONE NUmBER
i) Was the deceased receiving a benefi t?
Yes
No
If Yes, please state Benefit Type: ____________________
(j) Was the death of the deceased caused by an accident at work?
Yes
No
PART II. PARTICULARS OF THE CLAIMANT
(a) Name: _________________________________________________________________________________________
(Enter name as per Registration Card)
SURNAmE
FIRST
mIDDlE
(b) Social Security No:
(c) Date of Birth:
_______ /_______ /________
DAY
mONTH
YEAR
(d) Address: _______________________________________________________________________________________
HOUSE NO.
STREET
CITY/TOWN/VIllAGE
DISTRICT
__________________________________
______________________________
E-mAIl ADDRESS
PHONE NUmBER
(e) I claim Funeral Grant in respect of: (a) Spouse
(b) Dependent Child
(c) Deceased Insured Person
OR
(f) I have paid for the funeral expenses
I am liable to pay for the funeral expenses
.
Form FG.1 (August 2013)
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