"" 1 BENEFITS PAYMENT FORM 1. Personal Details. Please attach a copy of your ID for verification purposes. TitleMr.Mrs.Ms.Dr.Rev. First Name Surname Member ID Number SSNIT Number Mobile Number Email Date of Birth ID Number ID TypeSelect An OptionNational ID CardDriver's LicensePassportSSNIT ID CardNHIS ID Card Residential Address Mailing Address 2. Withdrawal Details Name of Scheme you are withdrawing fromUniversal Pension Master SchemeLegacy provident FundChrist Apostolic ChurchMichelettiRelianceLatex FoamFiesta RoyaleLARPS (Everyday Pension) Mechanical LlydTier 2Tier 3 GoilTier 2Tier 3 Reason for the Withdrawal Retirement at 60ResignationDismissalTerminationEarly RetirementSeverancePermanent Emigration form GhanaTotal IncapacityIn-ServiceDeath (Please provide death certificate and letters of administration) OtherPlease specify0 / Beneficiary Withdrawal (Please complete the beneficiary details and attach a copy of your ID for verification purposes) Name of Beneficiary Permanent Address Mobile Number Email Relationship to the ContributorSelect An OptionSpouseSonDaughterFatherMotherBrotherSisterNephewNieceUncleAuntFriend Date of Birth 3. Bank Payment Details (must be Member's / beneficiary's account details) Bank Name Bank Branch Name of Bank Account Bank Account Number Type of AccountSavingsCurrent Sort Code 4. Length of Service Date of Leaving Scheme Date of Joining Scheme Signature UploadUpload 5. Declaration I certify that the information provided on this form is correct and complete. I further authorize the Trustee (s) of the scheme (s) to process and pay my benefits to the bank account details I have indicated above. I understand that I will be liable to prosecution for any false declarations. Submit Form Previous Next Follow facebook Twitter Google+ LinkedIn Instagram Home Services About Contact Privacy Terms 233 Adom Street, Adenta Accra - Ghana email@example.com Call us on 0302 900 144 for assistance.