MOTOR INDUSTRY BARGAINING COUNCIL-MIBCO

(NATIONAL OFFICE)

PO BOX 4616

RANDBURG

2125

APPLICATION FOR EXEMPTION FROM THE MOTOR INDUSTRY ADMINISTERED PROVIDENT FUNDS

Name of Industry Fund in respect of which exemption is being applied for:

PLEASE NOTE THAT ALL PARTICULARS RELATE TO THE IN-HOUSE FUND

IMPORTANT:Please submit DETAILED RULES relevant to the In-House Fund.

  1. GENERAL INFORMATION

1.1Name of Employee: ______

1.2Trading name of Employer: ______

1.3Street Address: ______1.4 Postal Address: ______

______

______1.5 Tel No:______

1.6Name of Fund: ______

1.7Name of underwriter: ______

1.8If not underwritten by an insurer – Name of Fund’s Actuary: ______

1.9Telephone No. of Actuary:______

1.10Fund Registration number in terms of the Pension Act: ______

1.11Date of Registration: ______

  1. CONTRIBUTION RELATED INFORMATION

2.1What percentage of weekly / monthly wages/ salary does the EMPLOYER contribute towards the Fund?

2.2What percentage of weekly / monthly wages/ salary does the EMPLOYEE contribute towards the Fund?

2.3IMPORTANTAccompanying this application; a certificate, signed by the Fund’s Actuary, stating clearly the following:

2.3.1What percentage of the total contributions, is allotted towards:-

EMPLOYER CONTRIBUTIONEMPLOYEE CONTRIBUTION

2.3.1.1Administration Costs______

2.3.1.2Risk Benefits______

2.3.1.3Retirement Benefits______

2.4RETIREMENT AGES

2.4.1Normal RetirementMales: ______Females: ______

2.4.2Early RetirementMales: ______Females: ______

2.4.3Early III-Health retirement Males: ______Females: ______

  1. WITHDRAWAL BENEFIT INFORMATION

3.1RESIGNATION

Comprehensively state what benefit is payable to the member from:

3.1.1Member’s portion of contribution ______

3.1.2Interest (give full details) ______

3.1.3Any other (give full details) ______

3.1.4Employer’s portion of contribution ______

3.1.5Interest (give full details) ______

3.1.6Any other (give full details) ______

______

3.2DISMISSAL

Comprehensively state what benefit is payable to the member from:

3.2.1Member’s portion of contribution ______

3.2.2Interest (give full details) ______

3.2.3Any other (give full details) ______

______

3.2.4Employer’s portion of contribution ______

3.2.5Interest (give full details) ______

3.2.6Any other (give full details) ______

______

3.3RETRENCHMENT OR REDUNDANCY

Comprehensively state what benefit is payable to the member from:

3.3.1Member’s portion of contribution ______

3.3.2Interest (give full details) ______

3.3.3Any other (give full details) ______

______

3.3.4Employer’s portion of contribution ______

3.3.5Interest (give full details) ______

3.3.6Any other (give full details) ______

______

4.DISABILITY BENEFIT INFORMATION

4.1Is a Disability Benefit available? ______

4.2What are the conditions to qualify for this benefit? ______

______

4.3Comprehensively describe this benefit? ______

______

______

5.IN-SERVICE DEATH BENEFIT INFORMATION

5.1Is an In-Service Death Benefit provided? ______

5.2What are the conditions for the spouse of dependants to qualify for this benefit?

______

5.3Comprehensively describe this benefit? ______

______

______

6.HOUSING COLLATERAL

6.1Does the Fund provide for a housing collateral?

______

6.2At what interest rate?

______

  1. Any other information that might be applicable to motivate this application

______

______

______

The above Particulars are correct to the best of my knowledge and belief

Signed at ______this ______day of ______

______

Signature of Employer or authorised personDate