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AFFIDAVIT

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					                                 AFFID AVIT

 APPLICATION FOR ADMISSION OF IMMEDIATE FAMILY AND/OR COMMON LAW
                        SPOUSE OR PARTNER



I, _____________________________, ID Number ___________________do hereby
make oath and say:

1.    I am employed by _____________________________, am a member of
      MINEMED MEDICAL SCHEME and my Medical Scheme number is
      ___________


2.    I have the following dependant/s who is/are currently registered as my
      dependants on the Scheme:

                   Name                     Relationship to myself              Age




3.    ADDITION OF IMMEDIATE FAMILY (Parents and siblings only)               Ignore if not
      applicable

3.1   I now wish to add the following immediate family members (the Applicant/s) as my
       dependants on the Scheme:

             Name                 Relationship to myself         Age    Monthly income from
                                                                            all sources




3.2   I have a legal duty of support to the Applicant/s, the Applicant/s is/are unable to
      support him/herself and I am able to support the Applicant/s. A certified copy of
      the Applicant/s last tax return is attached hereto marked annexure A(i).

      My legal duty of support to the Applicant/s arises for the following reasons:

      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________

      The family care and support that I provide to the Applicant(s) is as follows:

      ________________________________________________________________
      ________________________________________________________________
      ________________________________________________________________
Affidavit                                     2


3.3.    I confirm that my dependant/s that are over the age of 18 years are not employed
        and earning an income of more than the social pension (R1010) per month.

4.      ADDITION OF COMMON LAW SPOUSE OR PARTNER                               Ignore if not
        applicable

        I now wish to add (full name) ______________________________________
        age ______ years as a dependant on account of him/her being my common-law
        spouse or partner.

        I confirm that we have a committed relationship akin to a marriage based on
        mutual dependency and a shared and common household.


5.      I declare that the information provided in this affidavit is true and correct in every
        respect and that should there be any material misrepresentation or nondisclosure
        of factual information in this affidavit I will be guilty of abusing the benefits and
        privileges of the Scheme and will have my membership terminated.




________________________
SIGNATURE OF MEMBER

I hereby certify that the deponent to this affidavit has acknowledged to me that he/she
has read and knows and understands its contents and that in compliance with the
regulations contained in Government Notice No.R1258 of the 21st July 1972 as
amended by Notice No.R1648 of 19th August 1977 it was signed and sworn to by
him/her before me at _______________ on this ______ day of ____________ 20 .




________________________
COMMISSIONER OF OATHS

				
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