an authorised Financial Service Provider in terms of the FAIS Act ( License No. 2409)
Liberty Centre, 1 Ameshoff Street, Braamfontein, 2001 P O Box 2094, Johannesburg 2000
Liberty Sentrum, Ameshoffstraat 1, Braamfontein 2001 Posbus 2094, Johannesburg 2000
Tel: (011) 408-2999 Fax/Faks: (011) 408-2158
E-mail address:
STATEMENT OF ADMISSION OF LIABILITY
I, the undersigned,Full Name
Identity Number
State that:
1. / I am an adult / (male/female), residing at
(full address).
2. / To my knowledge, the facts in this statement are true.
3. / I was employed by / (full name of my employer) (“my employer”),
a participating employer of the / Fund (full name of fund) (“the Fund”)
which I was a member of during my period of employment.
4. / I admit that my conduct as detailed below was wrong and unlawful and that is occurred as follows:
(Please describe the unlawful conduct in detail with dates and amounts where appropriate. As far as possible, mention and elaborate on all elements of the fraud, theft, dishonesty or misconduct.
For example, “I stole the sum of R1000 from my employer on (date) by forging cheques received from my employer’s clients. I deposited this money into my personal bank account for my own use and benefit.”
5. / My abovementioned unlawful and wrongful conduct caused my employer to suffer and sustain damages to the
sum of R / (state amount).
6. / This damages amount:
6.1 / Became due by me to my employer when I ceased employment/ceased to be a member of the Fund.
6.2 / Must be paid by me to my employer.
6.1 / Is in respect of compensation for damage I caused to my employer as a direct result of my previously stated wrongful and unlawful conduct.
7. / On termination of my employment I ceased to be a member of the Fund. A pension benefit will accrue/has accrued to me in terms of the Fund. (Use as appropriate.)
8. / I acknowledge that the Fund is accordingly entitled to deduct the compensation that is due to my employer from the pension benefit that will accrue/has accrued to me in terms of the rules of the Fund. (Use as appropriate.)
9. / The contents of this statement by me serves as the written admission of my liability to my employer in respect of the compensation as contained in Section 37(d)(ii)(aa) of the Pension Funds Act, 1956.
I made this statement freely and voluntarily, without being influenced and without constraint.
Signed at / this / day of / 20
SIGNATURE / WITNESS SIGNATURE
WITNESS SIGNATURE
Please note that in the event of any modification or variation of this standard form Liberty Corporate will regard this form as being
invalid and of no force and effect. Do not sign blank or incomplete forms.
LCB200 10/07