Marius Scheepers & Company Attorneys

mariusscheepers@irodo.com

Electronic Communications & Transactions Act Compliance:

Marius Scheepers & Company,
P.O. Box 38197,
Faerie Glen,
Pretoria,
South Africa,
0043

C/O 519 Spuy Street,
Sunnyside,
Pretoria

Telephone / Fax no.:
+27 (0)12 991 4487

Data / Fax no.:
+27 (0)82 565 5140

Mobile no.:
+27 (0)82 569 4198

Marius Scheepers and Company Attorneys and their associates accept no liability for any damages or losses suffered as a result of actions taken based on information contained herein. They are committed to regularly update all information that is subject to change from time to time. Any person may contact them for further information and to arrange for a consultation to deal with a specific issue or send an e-mail to mariusscheepers@irodo.com The information contained herein does not serve as alternative to legal advice that may be provided during a furrow assessment of the case at a proper consultation.

www.ccma.org.za
www.ccma.co.za
www.labour.org.za
www.irodo.com

UIF Forms

(updated 01/03)

UI-1
REGISTER TO CONFIRM CONTINUED UNEMPLOYMENT AND CONTINUED CAPACITY AND AVAILABILITY FOR WORK IN TERMS OF SECTION 17 (4) (d)

UI-1 UNEMPLOYMENT INSURANCE ACT 63 OF 2001 Register to confirm continued unemployment and continued capacity and availability for work in terms of section 17 (4) (d) read with regulation 3 (3)				I declare that - I have not been employed since I last signed this register, I am currently unemployed, since the last time I signed this register I have not received-
	v a monthly state pension (excluding a disability grant),
CONTRIBUTOR'S CHECK CARD				v a benefit from Compensation Fund for temporary or total disablement or
PAYPOINT	OFFICE STAMP			v a benefit from LRA Funds Employment Schemes and I am capable of and available for work
		If any of above is applicable complete following questions:
		When did you begin to receive this benefit? ____
TIME OF SIGNING				Do you continue to receive this benefit?_______
			If you no longer receive this benefit when did it come to an end? ________________________
VENUE				I understand that it is a criminal offence to sign this register and receive benefits while employed.
		NEXT SIGNING DATE	SIGNATURE OF CONTRIBUTOR	SIGNING OFFICIALS INITIAL


___________________________________ Signature of official
INFORMATION OUTSTANDING:
____________________________________________________
____________________________________________________
PERSONAL DETAILS:
Contributor's surname: _________________________________
Contributor's first names: _______________________________
Identity no.
Specimen Signature: __________________________________
Date Indicated on the reverse side is your next signing date.

UI-2.1
UNEMPLOYMENT INSURANCE BENEFITS IN TERMS OF SECTION 17 (1)

Read with regulation 3 (1)
1.	PERSONAL DETAIL
1.1	Identity Document:
1.2	Passport Number
1.3	Other Identity/Reference Number
1.4	Date of Birth
1.5	Gender		Male		5		Female	0
1.6	First Names
1.7	Surname
1.8	Previous Surname
1.9	Postal Address
	Code ...........................
1.10	Residential Address
	Code ...........................
1.11	Telephone No	Code ....................................
1.12	Cell No
1.13	E-Mail Address
1.14	SARS Number
2.	PAYMENT DETAILS
2.1	Name of Bank or Post office
2.2	Branch Code
2.3	Account Number
2.4	Account Type
3.	METHOD OF PAYMENT: (Use the UI-2.7 form for Banking Details)
	CHEQUE		CASH			BANK TRANSFER			OTHER
4.	EDUCATION BACKGROUND (tick the box)
	SPECIAL. SCHOOL CERT.			26	˜		BELOW GRADE 8			29	˜
	GRADE 8- 9			30	˜		GRADE 10 - 11			31	˜
	GRADE 12			32	˜		TERTIARY			33	˜

5.	EMPLOYER DETAILS
5.1	NAME OF EMPLOYER/COMPANY
5.2	UIF REF NUMBER
5.3	BUSINESS ADDRESS OF EMPLOYER:

5.4	POSTAL ADDRESS:
5.5	E-MAIL
5.6	Telephone Number	Code ......................
5.7	Fax Number
6.	EMPLOYMENT DETAILS
6.1	Occupation
6.2	Occ. Code
7.	PERIOD OF SERVICE
7.1	Commencement of employment with employer
7.2	Termination of Service
8.	REMUNERATION / SALARY
8.1	Gross pay (before deductions)
8.2	Salary Payment (PW or PM)
9.	SOURCES OF OTHER INCOME
	During this period of unemployment have you received income from any of these sources? (Tick the box)
9.1	Monthly Pension from State (Excluding Disability grant)		˜
9.2	Benefit from Compensation Fund for temporary or total disablement		˜
9.3	Benefits from an Unemployment Fund established by bargaining or statutory council		˜
9.4	None		˜
	When did you begin to receive this benefit? _____________________________________
	Do you continue to receive this benefit? ________________________________________
	If you no longer receive this benefit when did it come to an end? _____________________

10.	REASON FOR TERMINATION OF SERVICE
10.1	Dismissed
10.2	Contract Expired
10.3.1	Resigned
10.3.2	Constructive dismissal
10.4	Employer's insolvency
10.5	Other (Specify)
11.	FURTHER REQUIREMENTS
11.1.	Are you registered as workseeker with a Labour Centre established by the DOL
			*Yes* ˜ No ˜
11.2	If so, which Labour Centre: ______________________________________
11.3	Are you capable or and available for work?		*Yes* ˜ No ˜
		*Signature: _______________________*
11.4	If you are not capable or nor available for work, please explain: ____________
	_____________________________________________________________
*IMPORTANT: READ THIS SECTION BELOW:*
If your application is successful then the claims officer will authorise the payment of benefits. You must report to the employment office on a regular basis as indicated by the claims officer. You must also inform the claims officer as soon as you resume employment. I declare that the above information is true and correct. I understand that it is an offence to make a false statement.
Signature of applicant: _________________________ Date: _______/ ______/ ______

UI-2.2
APPLICATION FOR ILLNESS BENEFITS IN TERMS OF SECTION 22 (1)

Read with regulations 4 (1), 4 (5) and 4 (7))
1.	PERSONAL DETAIL
1.1	Identity Document:
1.2	Passport Number
1.3	Other Identity / Reference Number
1.4	Date of Birth
1.5	Gender		Male	5		Female	0
1.6	First Names
1.7	Surname
1.8	Previous Surname
1.9	Postal Address
	Code ......................
1.10	Residential Address
	Code ......................
1.11	Telephone No	Code ..............................
1.12	Cell No
1.13	E-Mail Address
1.14	SARS Number
2.	PAYMENT DETAILS
2.1	Name of Bank or Post Office
2.2	Branch Code
2.3	Account Number
2.4	Account Type
3.	METHOD OF PAYMENT: (Use the UI-2.7 form for Banking Details)
	CHEQUE		CASH		BANK TRANSFER			OTHER

4.	EMPLOYER DETAILS
4.1	NAME OF EMPLOYER/COMPANY
4.2	UIF REF NUMBER
4.3	BUSINESS ADDRESS OF EMPLOYER:

4.4	POSTAL ADDRESS:
4.5	E-MAIL
4.6	Telephone Number	Code ......................
4.7	Fax Number
5.	EMPLOYMENT DETAILS
5.1	Occupation
5.2	Occ. Code
6.	PERIOD OF SERVICE
6.1	Commencement of employment with employer
6.2	Termination of Service
7.	REMUNERATION / SALARY
7.1	Gross pay (before deductions)
7.2	Salary Payment (PW or PM)
8.	SOURCES OF OTHER INCOME
	During this period of unemployment have you received income from any of these sources? (Tick the box)
8.1	Monthly Pension from State (Excluding Disability grant)
8.2	Benefit from Compensation Fund for temporary or total disablement
8.3	Benefits from an Unemployment Fund established by bargaining or statutory council
8.4	None
	When did you begin to receive this benefit? ___________________________________
	Do you continue to receive this benefit? ______________________________________
	If you no longer receive this benefit when did it come to an end? ___________________

1.	ARE YOU STILL EMPLOYED	*YES* NO
	NB: IF YOU ARE STILL EMPLOYED, FORM UI-2.8 MUST BE COMPLETED.
2.	DATE OF COMMENCEMENT OF ILLNESS LEAVE: ______/______/______
3.	IF YOU HAVE RETURNED TO WORK, STATE DATE: ______/______/______
4.
	*MEDICAL CERTIFICATE (To be completed by an authorised practitioner in terms of section 20 (1) (c)* of the UI Act 63 of 2001.)**
	I, __________________________________ am a qualified ____________________
	My practice number is __________________. I confirm that _____________________ has been under my treatment from ______________ to ___________ and is suffering from ___________
	___________________________________________________________________________
	__________________________________ This patient was not capable of performing work from ___________________ to ____________ .
	If the nature of the illness is described in this medical certificate in uncertain terms or as 'disease - entity' or 'symptom complex', please furnish a clinical report describing the symptoms and nature of the complaint.
	Signature ____________________________ Date __________ Tel No. __________________
	Address __________________________________________________

*IMPORTANT : READ THIS SECTION BELOW:*
If your application is successful then the claims officer will authorise the payment of benefits. You must inform the claims officer as soon as you resume work. I declare that the above information is true and correct. I understand that it is an offence to make a false statement.
*SIGNATURE:______________________________ DATE: __________*

UI-2.3
APPLICATION FOR MATERNITY BENEFITS IN TERMS OF SECTION 25 (1)

Read with regulation 5 (1) and 5 (4)
1.	PERSONAL DETAIL
1.1	Identity Document:
1.2	Passport Number
1.3	Other Identity/Reference Number
1.4	Date of Birth
1.5	Gender		Male	5		Female	0
1.6	First Names
1.7	Surname
1.8	Previous Surname
1.9	Postal Address
	Code ......................
1.10	Residential Address
	Code ......................
1.11	Telephone No	Code ..............................
1.12	Cell No
1.13	E-Mail Address
1.14	SARS Number
2.	PAYMENT DETAILS
2.1	Name of Bank or Post Office
2.2	Branch Code
2.3	Account Number
2.4	Account Type
3.	METHOD OF PAYMENT: (Use the UI-284 form for Banking Details)
	CHEQUE		CASH		BANK TRANSFER			OTHER

4.	EMPLOYER DETAILS
4.1	NAME OF EMPLOYER/COMPANY
4.2	UIF REF NUMBER
4.3	BUSINESS ADDRESS OF EMPLOYER:

4.4	POSTAL ADDRESS:
4.5	E-MAIL
4.6	Telephone Number	Code ......................
4.7	Fax Number
5.	EMPLOYMENT DETAILS
5.1	Occupation
5.2	Occ. Code
6.	PERIOD OF SERVICE
6.1	Commencement of employment with employer
6.2	Termination of Service
7.	REMUNERATION / SALARY
7.1	Gross pay (before deductions)
7.2	Salary Payment (PW or PM)
8.	SOURCES OF OTHER INCOME
	During this period of unemployment have you received income from any of these sources? (Tick the box)
8.1	Monthly Pension from State (Excluding Disability grant)
8.2	Benefit from Compensation Fund for temporary or total disablement
8.3	Benefits from an Unemployment Fund established by bargaining or statutory council
8.4	None
	When did you begin to receive this benefit? ___________________________________
	Do you continue to receive this benefit? ______________________________________
	If you no longer receive this benefit when did it come to an end? ___________________

1.	ARE YOU STILL EMPLOYED	*YES* NO
	NB: IF YOU ARE STILL EMPLOYED, FORM UI-2.8 MUST BE COMPLETED.
2.	DATE OF COMMENCEMENT OF MATERNITY LEAVE: ______/______/______
3.	IF YOU HAVE RETURNED TO WORK, STATE DATE: ______/______/______
4.
	MEDICAL CERTIFICATE (to be completed by a medical practitioner or registered midwife)
	I, ______________________________________________ am a qualified ______________________________ My practice number is __________________. I confirm that____________________________ is under my treatment and is pregnant. The expected due date of birth is _______________________
	OR
	I confirm that ___________________________ gave birth on ______________. \ The baby was stillborn on __________________________ \ had a miscarriage on ________________________.
	Signature ______________________ Date __________ Tel No. ________________
	Address ____________________________________________________________

*IMPORTANT : READ THIS SECTION BELOW:*
If your application is successful then the claims officer will authorise the payment of benefits. You must also inform the claims officer as soon as you resume employment. I declare that the above information is true and correct. I understand that it is an offence to make a false statement.
*SIGNATURE OF APPLICANT: ______________________________ DATE: __________*

UI-2.4
APPLICATION FOR ADOPTION BENEFITS IN TERMS OF SECTION 28 (1)

Read with regulation 6 (1)
1.	PERSONAL DETAIL
1.1	Identity Document:
1.2	Passport Number
1.3	Other Identity/Reference Number
1.4	Date of Birth
1.5	Gender		Male	5		Female	0
1.6	First Names
1.7	Surname
1.8	Previous Surname
1.9	Postal Address
	Code ......................
1.10	Residential Address
	Code ......................
1.11	Telephone No	Code ..............................
1.12	Cell No
1.13	E-Mail Address
1.14	SARS Number
2.	PAYMENT DETAILS
2.1	Name of Bank or Post Office
2.2	Branch Code
2.3	Account Number
2.4	Account Type
3.	METHOD OF PAYMENT: (Use the UI-2.7 form for Banking Details)
	CHEQUE		CASH		BANK TRANSFER			OTHER

4.	EMPLOYER DETAILS
4.1	NAME OF EMPLOYER/COMPANY
4.2	UIF REF NUMBER
4.3	BUSINESS ADDRESS OF EMPLOYER:

4.4	POSTAL ADDRESS:
4.5	E-MAIL
4.6	Telephone Number	Code ......................
4.7	Fax Number
5.	EMPLOYMENT DETAILS
5.1	Occupation
5.2	Occ. Code
6.	PERIOD OF SERVICE
6.1	Commencement of employment with employer
6.2	Termination of Service
7.	REMUNERATION / SALARY
7.1	Gross pay (before deductions)
7.2	Salary Payment (PW or PM)
8.	SOURCES OF OTHER INCOME
	During this period of unemployment have you received income from any of these sources? (Tick the box)
8.1	Monthly Pension from State (Excluding Disability grant)
8.2	Benefit from Compensation Fund for temporary or total disablement
8.3	Benefits from an Unemployment Fund established by bargaining or statutory council
8.4	None
	When did you begin to receive this benefit? ___________________________________
	Do you continue to receive this benefit? ______________________________________
	If you no longer receive this benefit when did it come to an end? ___________________

1.	ARE YOU STILL EMPLOYED	*YES* NO
	NB: IF YOU ARE STILL EMPLOYED, FORM UI-2.8 MUST ALSO BE COMPLETED.
2.	DATE OF COMMENCEMENT OF ADOPTION LEAVE: ______/______/______
3.	IF YOU HAVE RETURNED TO WORK, STATE DATE: ______/______/______
*IMPORTANT : READ THIS SECTION BELOW*
If your application is successful then the claims officer will authorise the payment of benefits. You must also inform the claims officer as soon as you resume work. I declare the above information is true and correct. I understand that it is an offence to make a false statement.
*SIGNATURE: ______________________________ DATE: __________*

UI-2.5
APPLICATION FOR DEPENDANT'S BENEFITS BY SURVIVING SPOUSE OR LIFE PARTNER IN TERMS OF SECTION 31 (1)

Read with regulation 7 (1)

PARTICULARS OF SURVIVING SPOUSE OR LIFE PARTNER: (NOTE: In the case of a surviving spouse if there is not a marriage certificate recognised as valid in terms of any law relating to marriage in force in the Republic of South Africa, supplementary documents required by the department regarding the circumstances of the matter should be attached)

1.	PERSONAL DETAIL[S]
1.1	Identity Document:
1.2	Passport Number
1.3	Other Identity/Reference Number
1.4	Date of Birth
1.5	Date of Death
1.6	Gender	Male			5	Female	0
1.7	First Names
1.8	Surname
1.9	Previous Surname
1.10	Last Residential Address			Code ...............
	Code .....................
1.11	Telephone No
1.12	Cell No
1.13	E-Mail Address
1.14	SARS Number
2.	EMPLOYER DETAILS
2.1	NAME OF EMPLOYER/COMPANY
2.2	UIF REF NUMBER
2.3	BUSINESS ADDRESS OF EMPLOYER:

2.4	POSTAL ADDRESS:
2.5	E-MAIL
2.6	Telephone Number		Code ................
2.7	Fax Number

3.	EMPLOYMENT DETAILS
3.1	Occupation
3.2	Occ. Code
4.	PERIOD OF SERVICE
4.1	Commencement of employment with employer
4.2	Termination of Service
5.	REMUNERATION / SALARY
5.1	Gross pay (before deductions)
5.2	Salary Payment (PW or PM)
6.	PERSONAL DETAILS OF SPOUSE OR LIVE [sic] PARTNER
6.1	Identity Document:
6.2	Passport Number
6.3	Other Identity/Reference Number
6.4	Date of Birth
6.5	Gender	Male		5	Female	0
6.6	First Names
6.7	Surname
6.8	Previous Surname
6.9	Postal Address
	Code ...............
6.10	Residential Address
	Code ...............
6.11	Telephone No		Code .....................
6.12	Cell No
6.13	E-Mail Address
6.14	SARS Number

7.	PAYMENT DETAILS
7.1	Name of Bank or Post Office
7.2	Branch Code
7.3	Account Number
7.4	Account Type
8.	METHOD OF PAYMENT: (Use the UI-2.7 form for Banking Details)
	CHEQUE	BANK TRANSFER	OTHER

*IMPORTANT : READ THIS SECTION BELOW*
I declare that I am the only surviving spouse or life partner or one of ________________ surviving spouses of the abovementioned deceased contributor, that I was not divorced from him/her and that information given in this document is true and correct. I understand that it is an offence to make a false statement.
*SIGNATURE OF SURVIVING SPOUSE OR LIFE PARTNER: ____________________*
DATE: _____/ _____/ _____

UI-2.6
APPLICATION FOR DEPENDANT'S BENEFITS BY CHILD OF DECEASED IN TERMS OF SECTION 31 (1)

Read with regulation 7 (1) and 7 (2)
1.	PERSONAL DETAIL[S]
1.1	Identity Document:
1.2	Passport Number
1.3	Other Identity/Reference Number
1.4	Date of Birth
1.5	Date of Death
1.6	Gender	Male			5	Female	0
1.7	First Names
1.8	Surname
1.9	Previous Surname
1.10	Last Residential Address			Code ...............
	Code .....................
1.11	Telephone No
1.12	Cell No
1.13	E-Mail Address
1.14	SARS Number
2.	EMPLOYER DETAILS
2.1	NAME OF EMPLOYER/COMPANY
2.2	UIF REF NUMBER
2.3	BUSINESS ADDRESS OF EMPLOYER:

2.4	POSTAL ADDRESS:
2.5	E-MAIL
2.6	Telephone Number		Code ................
2.7	Fax Number

3.	EMPLOYMENT DETAILS
3.1	Occupation
3.2	Occ. Code
4.	PERIOD OF SERVICE
4.1	Commencement of employment with employer
4.2	Termination of Service
5.	REMUNERATION / SALARY
5.1	Gross pay (before deductions)
5.2	Salary Payment (PW or PM)
6.	GUARDIANS PERSONAL DETAILS:
	RELATIONSHIP OF GUARDIAN TO DECEASED: ______________________________________
6.1	Identity Document:
6.2	Passport Number
6.3	Other Identity/Reference Number
6.4	Date of Birth
6.5	Gender	Male		5	Female	0
6.6	First Names
6.7	Surname
6.8	Previous Surname
6.9	Postal Address
	Code ...............
6.10	Residential Address
	Code ...............
6.11	Telephone No		Code .....................
6.12	Cell No
6.13	E-Mail Address
6.14	SARS Number

CHILD'S DETAILS (1)

7.1

Identity Document:

7.2

Date of Birth

7.3

Gender

Male

Female

7.4

First Names

7.5

Surname

7.6

Postal Address

Code............................

7.7

Residential Address

Code...........................

PAYMENT DETAILS of Guardian *

8.1

Name of Bank or Post Office

8.2

Branch Code *

8.3

Account Number

8.4

Account Type

METHOD OF PAYMENT: (Use the UI-2.7 form for Banking Details)

CHEQUE

BANK TRANSFER

OTHER

IMPORTANT : READ THIS SECTION BELOW

I declare that the information is true and correct. I understand that it is an offence to make a false statement..

SIGNATURE OF APPLICANT: _______________________________________

DATE: ___/ ___/ __

UI-2.7
STATEMENT IN RESPECT OF PAYMENT MADE TO THE UNDERMENTIONED CONTRIBUTOR WHO IS STILL IN MY EMPLOYMENT BUT IS UNABLE TO WORK DUE TO ILLNESS, MATERNITY OR ADOPTION OF A CHILD

TO: CLAIMS OFFICER

Employers UIF Reference No.

Full names of contributor: ____________________________________________________________________________

ID No of contributor.:

(A)

In terms of section 19 (1), 24 (2) and 27 (3) of the abovementioned Act

I hereby certify that since _____/_____/_____, the contributor is on sick leave / maternity / leave due to the adoption of a child and has/will receive the following remuneration.

GROSS PAY (before deduction) PM/PW

WHEN DID CONTRIBUTOR STOP WORK ON ACCOUNT OF ILLNESS/MATERNITY OR ADOPTION LEAVE

REMUNERATION DURING ILLNESS/MATERNITY OR ADOPTION LEAVE PAID TO CONTRIBUTOR (PM/PW)

FROM

(B)

The contributor is expected to return to work on\has returned to work on _________/_________/_________.

(C)

Kindly state whether you are in receipt OF INCOME FROM OTHER SOURCES

(mark X where applicable)

MONTHLY PENSION FROM STATE (Excluding Disability grant)

BENEFIT FROM COMPENSATION FUND FOR TEMPORARY OR TOTAL DISABLEMENT

BENEFITS FROM AN UNEMPLOYMENT FUND ESTABLISHED BY BARGAINING OR STATUTORY COUNCIL

NONE

If mark X on 1-3:
When did you begin to receive this benefit? ___________________________
Do you continue to receive this benefit? ______________________________
If you no longer receive this benefit when did it come to an end? _________________________________________________

DATE: ____________

___________________________________________
SIGNATURE OF EMPLOYER OR AUTHORISED AGENT

BUSINESS STAMP

UI-2.8
APPLICATION TO PAY BENEFITS INTO BANKING ACCOUNT

The Unemployment Insurance Commissioner/Provincial Director
I, ________________________________________________________________________________, (Full name and surname in block letters)
Identity number hereby request/instruct/authorise you to pay my benefits, if approved into my account at the undermentioned Bank/Building Society account.
I understand that the credit transfers hereby authorized, will be processed by computer through a system known as ACB Magnetic Tape Service, and I also understand that no advice of payment will be provided by my bank, but details of each payment will be printed on my bank statement. (This does not apply where it is not customary for banks to furnish bank statements, eg. Savings accounts or transmission accounts).
This authority may be cancelled by me by giving thirty days notice in writing.
NB: Documentary proof of bank account (eg. Bank statement, ATM slip, cancelled cheque) must be attached.
_______________________________________ Signature of applicant				___________________ Date
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
To be completed ONLY by the Bank / Building Society
Name of account holder _______________________________________________
Name of Bank/Building Society ______________________________________________
Branch code		Account number
Indicate with an 'X'
Savings account			Current account	Transmission account

Other	;		Specify:
I declare that the abovementioned information is current and complete in every aspect and that the Unemployment Insurance Commissioner will not be held liable for any incorrect payment which might arise due to incorrect/incomplete information supplied by me.
Information supplied by: _______________________________________ Date: _________________ (Name of Bank Official)
______________________________________ Signature of Bank Official				Bank Official Stamp

UI-3
APPLICATION FOR CONTINUATION OF PAYMENT FOR ILLNESS BENEFITS IN TERMS OF REGULATION 4 (4)

*FORM MUST BE COMPLETED ON OR AFTER*				ID NO.
	I, hereby apply for continuation of illness benefits for the period of ____________________ to _____________________.
	1.	Surname:
	2.	Previous surname: (Only if it changed since your previous application)
	3.	First names:
	4.	Identity number:	5.	Telephone number:
	6.	Postal address:
	7.	Residential address: (If different from postal address)		Postal code

	8.	Date returned to work: ____/____/___________
	9.	Kindly state whether you are in receipt of income from other sources. Tick () where applicable.
	1.	Monthly Pension from State (Excluding Disability grant)		I declare, except as stated in item 8, that I have not worked since the date of my application for illness benefits and have not been entitled to my normal remuneration/or will receive a portion of my normal remuneration as declared by my employer on prescribed form UI-125 submitted with my application form.
	2.	Benefit from Compensation Fund for temporary or total disablement
	3.	Benefits from an Unemployment Fund established by bargaining or statutory council
	4.	NONE
	If any of above is applicable complete following questions: When did you begin to receive this benefit? _________________ Do you continue to receive this benefit? ____________________ If you no longer receive this benefit when did it come to an end? _______________________			I furthermore declare that the information given is true and correct. I am aware that it is an offence to willfully make a false statement. _____________________ ____/____/_____ Signature of applicant Date
	NB: IF YOUR BANKING DETAILS HAVE CHANGED, A FORM UI-284 MUST BE COMPLETED
MEDICAL CERTIFICATE (To be completed by an authorised practitioner in terms of section 20 (1) (c) of Act 63 of 2001)
I, _____________________________________________________ am a qualified ___________________________
My practice number is _____________________________________. I confirm that ____________________________
has been under my treatment from _____________ to _____________ and is suffering from _____________________
______________________________________________________________________________________________
This patient was not capable of performing work from ______________ to ____________
If the nature of the illness is described in this medical certificate in uncertain terms or as 'disease - entity' or 'symptom complex', please furnish a clinical report describing the symptoms and nature of the complaint.
Signature __________________________________ Date ____________________ Tel No. _________________
Address ____________________________________________________________________

UI-4
APPLICATION FOR CONTINUATION OF PAYMENT FOR MATERNITY BENEFITS IN TERMS OF REGULATION 5 (3) AND 5 (6)

*FORM MUST BE COMPLETED ON OR AFTER*				ID NO.
	I, hereby apply for continuation of illness benefits for the period of ____________________ to _____________________.
	1.	Surname:
	2.	Previous surname: (Only if it changed since your previous application)
	3.	First names:
	4.	Identity number:	5.	Telephone number:
	6.	Postal address:
	7.	Residential address: (If different from postal address)		Postal code

	8.	Date returned to work: ____/____/___________
	9.	Kindly state whether you are in receipt of income from other sources. Tick () where applicable.
	1.	Monthly Pension from State (Excluding Disability grant)		I declare, except as stated in item 8, that I have not worked since the date of my application for illness benefits and have not been entitled to my normal remuneration/or will receive a portion of my normal remuneration as declared by my employer on prescribed form UI-125 submitted with my application form.
	2.	Benefit from Compensation Fund for temporary or total disablement
	3.	Benefits from an Unemployment Fund established by bargaining or statutory council
	4.	NONE
	If any of above is applicable complete following questions: When did you begin to receive this benefit? _________________ Do you continue to receive this benefit? ____________________ If you no longer receive this benefit when did it come to an end? _______________________			I furthermore declare that the information given is true and correct. I am aware that it is an offence to willfully make a false statement. _____________________ ____/____/_____ Signature of applicant Date
	NB: IF YOUR BANKING DETAILS HAVE CHANGED, A FORM UI-284 MUST BE COMPLETED
NOTIFICATION OF BIRTH (regulation 5 (6))
I, declare that my baby was born on ____________ / the baby was stillborn on _________ / I had a miscarriage on _________
Signature of applicant ____________________________ Date ___________
MEDICAL CERTIFICATE - Should only be completed once, after confirmation of birth by a medical practitioner/registered midwife.
I, _____________________________________________________, qualifications _________________________________
confirm that _____________________________ gave birth on _______________________________.\ The baby was stillborn
on ____________________ \ had a miscarriage on _________________________.
Signature _____________________ Date ________________ Tel No. __________
Address _________________________________________________________________________________________

UI-5
APPLICATION FOR CONTINUATION OF PAYMENT FOR ADOPTION BENEFITS IN TERMS OF REGULATION 6 (3)

*FORM MUST BE COMPLETED ON OR AFTER*				ID NO.
	I, hereby apply for continuation of adoption benefits for the period of ____________________ to _____________________.
	1.	Surname:
	2.	Previous surname: (Only if it changed since your previous application)
	3.	First names:
	4.	Identity number:	5.	Telephone number:
	6.	Postal address:
	7.	Residential address: (If different from postal address)		Postal code

	8.	Date returned to work: ____/____/___________
	9.	Kindly state whether you are in receipt of income from other sources.
		Tick () where applicable.
	1.	Monthly Pension from State (Excluding Disability grant)		I declare, except as stated in item 8, that I have not worked since the date of my application for illness benefits and have not been entitled to my normal remuneration/or will receive a portion of my normal remuneration as declared by my employer on prescribed form UI-125 submitted with my application form.
	2.	Benefit from Compensation Fund for temporary or total disablement
	3.	Benefits from an Unemployment Fund established by bargaining or statutory council
	4.	NONE
	If any of above is applicable complete following questions: When did you begin to receive this benefit? _________________ Do you continue to receive this benefit? ____________________ If you no longer receive this benefit when did it come to an end? _______________________			I furthermore declare that the information given is true and correct. I am aware that it is an offence to willfully make a false statement. _____________________ ____/____/_____ Signature of applicant Date
	NB: IF YOUR BANKING DETAILS HAVE CHANGED, A FORM UI-284 MUST BE COMPLETED

UI 12
NOTICE OF APPEAL AGAINST A DECISION OF THE COMMISSIONER OR A CLAIMS OFFICER

Application in terms of section 37 (1) read with regulation 8 (1)

A person entitled to benefits in terms of the Act may appeal against a decision of the Commissioner to suspend that person's right to benefits, or a decision of a claims officer relating to the payment of non payment of benefits. This Notice of appeal must be sent to the Appeal Committee, Unemployment Insurance Board, 94 Church Street, Pretoria, 0002.
1.	Personal details
	1.1	Name _____________________________________________________________
	1.2	ID number __________________________________________________________
	1.3	Passport number ____________________________________________________
	1.4	Residential address __________________________________________________
	1.5	Postal address ______________________________________________________
	1.6	E-mail address ______________________________________________________
	1.7	Tel number (include the code) ___________________________________________
	1.8	Cell number ________________________________________________________
2.	Employer details
	2.1	Name of employer (prior to unemployment) ________________________________
	2.2	UIF reference number _________________________________________________
	2.3	Physical address ____________________________________________________
	2.4	Postal address ______________________________________________________
	2.5	E-mail address ______________________________________________________
	2.6	Tel number _________________________________________________________
	2.7	Fax number _________________________________________________________
3.	Decision appealed against
	3.1	What decision are you appealing against?
		__________________________________________________________________
	3.2	Which body made the decision?
		__________________________________________________________________
	3.3	When was the decision made?
		__________________________________________________________________

	3.4	When were you notified about the decision?
		__________________________________________________________________
	3.5	Why are you appealing against the decision?
		__________________________________________________________________
	3.6	In what respects do you think the decision is incorrect or unfair?
		__________________________________________________________________
		__________________________________________________________________
		_____________________________________________________________
	3.7	What outcome do you seek from this appeal?
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
Signature		_______________________ Date __________________
For official purposes
On the _______ the Appeal Committee decided that the appeal was
Successful
Unsuccessful because ____________________________________
Signature of chairperson _________________________ Date ___________________________

UI 13
REFERRAL OF DISPUTE TO CCMA FOR ARBITRATION

Application in terms of section 37 (2) read with regulation 9 (1)

A person who is dissatisfied with the decision of the Appeal Committee may refer a dispute to the CCMA for arbitration within 30 days of receiving notification of the decision.
The person referring the dispute must serve it on the Commissioner by hand, registered post or fax, and then on to the CCMA (with proof of this service) in the province in which the application for benefits was considered.
1.	Personal details
	1.1	Surname _________________________________________________________
	1.2	First Name ________________________________________________________
	1.3	ID number ________________________________________________________
	1.4	Passport number ___________________________________________________
	1.5	UIF number (Employers reference No ___________________________________
	1.6	Residential address _________________________________________________
		_________________________________________________________________
	1.7	Postal address _____________________________________________________
	1.8	E-mail address _____________________________________________________
	1.9	Tel number (include the code) _________________________________________
	1.10	Fax number (include the code) _________________________________________
	1.11	Cell number _______________________________________________________
2.	Dispute details
	2.1	What is the nature of the dispute (ie what is the dispute about)?
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		_________________________________

	2.2	What factors do you think the Appeal Committee failed to consider?
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		_____________________
	2.3	What other information do you want to draw to the CCMA's attention?
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		________________________________________________
	2.4	What outcome do you seek from this arbitration?
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		_________________________________
3.	Documents to attach to this form:
	3.1	Your Notice of appeal against a decision of the Commissioner or a claims officer
	3.2	The decision from the Appeal Committee
	3.3	Use additional pages if required
Signature		______________________________ Date _______________________

UI 14
RECORD OF UNDERTAKING

Record of undertaking in terms of section 38 read with regulation 10 (1)

A labour inspector may secure an undertaking from an employer who has failed to comply with certain provisions of the Act.
I (name) ________________________________________ ID No ______________________
representing the employer (name of employer) ____________________________________ located
at (address of employer) _______________________________________________
____________________________________________________________________________
admit that the employer has failed to comply with the Act in the following respects-
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
______________________________________________________________________________
__________________________________________________________________
____________________________________________________________________________
The employer undertakes to rectify these acts or omissions by-
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________________________________________________
Signature of authorised employer representative	____________________________
Name of labour inspector	____________________________
Signature of labour inspector	____________________________
Witnesses	____________________________
Date	____________________________

UI 15
RECEIPT OF PAYMENT BY EMPLOYER

Receipt of payment in terms of section 38 (2) (c) read with regulation 10 (2)

A labour inspector must provide a receipt in respect of payment received from an employer

I, _______________________________ ID No ________________________ an inspector in the

Department of Labour, appointed in terms of the Act, acknowledge receipt of the amount

R_______ ___ (sum also in words) _________________________________________________

from _______________________ (employer's name) being an amount owed to

_____________________________ in terms of section _____________________

of the Act 63 of 2001, and/or in terms of an undertaking dated ______________________________

The amount was paid by (cheque / cash / other) ____________________________

Received by: ______________________________

Designation: ______________________________

Date: ______________________________

UI 16
ISSUE OF COMPLIANCE ORDER

Issue of compliance order in terms of section 39 (1) and 39 (2) read with regulation 11

A labour inspector may issue a compliance order if he or she has reasonable grounds to believe than an employer has not complied a provision of the Act.
An employer may object to the Director-General, Labour within 30 days of receiving this order.
1.	Employer details
	1.1	Name of employer _________________________________________________
	1.2	Physical address __________________________________________________
		________________________________________________________________
	1.3	Postal address ___________________________________________________
	1.4	E-mail address ___________________________________________________
	1.5	Address of each workplace __________________________________________
		________________________________________________________________
	1.6	Tel number (include the code) ________________________________________
	1.7	Fax number (include the code) ________________________________________
2.	Non compliance details
	2.1	You have failed to comply with the following section of the Act ________________
	2.2	You have failed to comply with a written undertaking in that you-
		__________________________________________________________________
		__________________________________________________________________
		____________________________________________________________
	2.3	The extent of your non compliance is as follows:
		__________________________________________________________________
		__________________________________________________________________
		_____________________________________________________

3.	The order
	3.1	You are ordered to pay the Fund the amount of _______________________
	3.2	You are ordered to take the following steps:
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		____________________________________________________________
	3.3	If you fail to comply with the above the following steps maybe taken:
		__________________________________________________________________
		__________________________________________________________________
		__________________________________________________________________
		________________________________________
		____________________________________________________________
Name of labour inspector			_______________________
Signature of labour inspector			_______________________
Date of issue			_______________________
Date of service of compliance order to employer			_______________________
Received by employer			_______________________

UI 17
OBJECTION TO COMPLIANCE ORDER

Objection to compliance order in terms of section 40 read with regulation 12

An employer may object to a compliance order within 30 days of receiving the order by referring the dispute for resolution to the Director-General, Labour.
1.	Employer details
	1.1	Name of employer __________________________________________________
	1.2	Physical address ___________________________________________________
	1.3	Postal address _____________________________________________________
	1.4	E-mail address _____________________________________________________
	1.5	Tel number (include the code) _________________________________________
	1.6	Fax number (include the code) _________________________________________
2.	Objection details
	2.1	To which portion of the compliance order do you object?
		_________________________________________________________________
	2.2	What is the nature of your objection?
		_________________________________________________________________
		_________________________________________________________________
	2.3	Is there any other information you wish to draw to the Director's-General attention?
		_________________________________________________________________
	2.4	What outcome do you seek from this objection?
		_________________________________________________________________
3.	Documents
	You must include:
	3.1	The compliance order	3.2	Record of undertaking (if applicable)
Signature		_______________________	Date	_________________________

UNDER CONSTRUCTION