Form Fw02n - Nominee Claim Withdrawal Application - Fiji National Provident Fund (Page 3 of 4) in pdf

Form Fw02n - Nominee Claim Withdrawal Application - Fiji National Provident Fund Page 3

SECTION D – PAYMENT DETAILS

You are required to complete this section indicating the method of payment and payment details:

Deposit to my local bank account:

Account Name:

Bank Name:

Account No:

Deposit to my Overseas bank account via Telegrahic Transfer:

Account Name:

Bank Name:

Account No:

BSB/ Routing:

Number

Swift Code:

Bank Address:

Mail Bank Draft to my Overseas address:

SECTION E – NOMINATION

Note: If you have purchased a retirement package it is compulsory to complete this section

Name: ________________________________________________________________

1 passport size

Relationship: ___________________________________________________________

photo of Nominee

duly certified by JP/

Commissioner of Oath

Date of Birth: ___________________________________________________________

Address: ______________________________________________________________

SECTION F – DECLARATION

I understand and agree to:

(a) I hereby indemnify the FNPF Board from any liability whatsoever, including any loss benefits that may arise as a conse-

quence of approving my application.

(b) My application is subject to the provisions FNPF Decree 2011, and all such terms and conditions that may be imposed from

time to time.

Signature of Nominee: __________________________

Date: ____________________

Signature of Witness: __________________________

Date: ____________________

Name of Witness: ______________________________________________________________

Address of Witness : ___________________________________________________________

Left Thumbprint of Nominee

Form Fw02n - Nominee Claim Withdrawal Application - Fiji National Provident Fund Page 3