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Application for Death Benefit
Application for Death Benefit
Step
1
of
2
50%
Applicant’s Name
First
Last
I.D
Address
Phone (HOME)
CELL
Name of Deceased
Date of Death
MM slash DD slash YYYY
Relationship to Applicant
Date
MM slash DD slash YYYY
Official Use Only
Amount of Benefit
Date of Payment
MM slash DD slash YYYY
Cheque No.
Prepared by
Death Certificate Pin No
Ledger No.
Approved by
First
Last
Date
MM slash DD slash YYYY
