APS

Disability Request Form

Step 1. Please complete the ‘Disability Pension Benefit Request’ form below.
Step 2. Once completed, please click ‘Submit’ and then click ‘Download form’
Step 3. Please print your completed form and sign the form with your name and signature.
Step 4. Please scan your signed form, upload it and click ‘Submit’

Please note that it is necessary to include the following documents with this registration:

  • Copy of valid picture ID (passport, ID card, driver’s license)
  • Detailed Extract form Civil Registry (“Uitgebreid uittreksel Burgerzaken”)
  • Salary specification letter from your last employer(s) stating the salary amounts earned from January 2018 until retirement date and confirming your employment history (for verification purposes)
  • Proof of additional income from business or other employment that is subjected to wage tax
  • Copy of bank statement/bank book (for verification purposes)

DISABILITY PENSION BENEFIT REQUEST FORM

SUBMITTER

Name(Required)
DD slash MM slash YYYY
Sex(Required)
Address(Required)
Marital Status(Required)
Preferences

CURRENT SPOUSE (ONLY IF MARRIED)

Name
Sex
DD slash MM slash YYYY
DD slash MM slash YYYY

DEPENDENTS*

*Dependents are classified as children who are: • younger than the age of 18 years and financially dependent on you; • between the ages of 18 and 27, attending school and financially dependent on you; • between the ages of 18 and 27, financially dependent on you, physically or mentally disabled and earning less than 1/3 of the income of able-bodied someone in the same age bracket.
Name
DD slash MM slash YYYY
Name
DD slash MM slash YYYY
Name
DD slash MM slash YYYY
Name
DD slash MM slash YYYY

EX-SPOUSE(S) (ONLY IF DIVORCED)

Name
DD slash MM slash YYYY
DD slash MM slash YYYY
DD slash MM slash YYYY
Please provide
Max. file size: 100 MB.
Please upload your Divorce Decree here.
Name
DD slash MM slash YYYY
DD slash MM slash YYYY
DD slash MM slash YYYY
Please provide
Max. file size: 100 MB.
Please upload your Divorce Decree here.

EMPLOYMENT DETAILS

MM slash DD slash YYYY
Other Income(Required)

BANK DETAILS

Note: This must be a local or ING account.
Bank(Required)

Bank Address(Required)
Account Type(Required)
Currency Type(Required)
Note: This must be a local or ING account.

UPLOAD NECESSARY DOCUMENTS

Please ensure that the documents substantiating your pension request are submitted with this form.
Max. file size: 100 MB.
Max. file size: 100 MB.
Max. file size: 100 MB.
Max. file size: 100 MB.
Max. file size: 100 MB.

To sign this form, please follow the steps below:

1. Submit and download your form. 2. Write your full name and sign your form. 3. Please click on the 'Upload signed form' button below.
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