GUIDELINES TO COMPLETING THE PERMANENT EMIGRATION

DECLARATION FORM (SS-B11b)

1. An Applicant whose Home Mission is unable to endorse Part IV of the Emigration Lumpsum
Benefit Application (SS-B11a) Form, shall complete Part V of the SS-B11a Form.

2. The Applicant shall contact a Notary Public of his/her choice in Ghana to notarize the completed
Permanent Emigration Declaration (SS-B11b) Form.

3. The Applicant shall contact a Notary Public from the Émigré’s Home Country to notarize a
copy of any one (1) of the under-listed Documents:

i. Passport (personal details page only)

ii. Exit Travel Ticket
iii. Certificate of Permanent Residence
iv. Certificate of Naturalisation

4. The Émigré shall then send by Courier (e.g. Fedex, DHL) the under-listed Documents to any
SSNIT Branch of his/her choice:

i. Completed Emigration Lumpsum Benefit Application (SS-B11a) Form

ii. Completed and notarized Permanent Emigration Declaration (SS-B11b) Form.
iii. A notarized copy of Émigré’s Exit Travel Ticket
iv. A copy of any one (1) of the following Documents (notarized in Émigré’s Home
Country):

a. Passport (personal details page only)

b. Certificate of Permanent Residence
c. Certificate of Naturalisation
 REPUBLIC OF GHANA
SOCIAL SECURITY AND NATIONAL INSURANCE TRUST SS-B11a
EMIGRATION LUMPSUM BENEFIT APPLICATION FORM

All PARTS must be completed in BLACK or BLUE INK and in BLOCK LETTERS only.

PART I: APPLICANT’S PERSONAL DETAILS

Social Security Number

Surname

First Name

Other Name(s)

Date of Birth Date of Retirement

Do you have students’ loan obligation? YES NO

PART II: CONTACT DETAILS

CURRENT MAILING ADDRESS

C/o

Institution

Postal Type (Tick ( ) only one) P. O. BOX PMB DTD Post Box Number

Post Box
Town/City
Location

Region

Mobile Phone No.

Phone No. (Abroad)
(Ghana)

E-mail Address

Preferred Channel of Communication Post Mobile Other Phone E-mail

RESIDENTIAL ADDRESS/LOCATION (GHANA) RESIDENTIAL ADDRESS/LOCATION (ABROAD)

House Number House Number

Street Name Street Name

Town/City Town/City

Country Country

Landmark (e.g. Near/Opposite a School/Church/Palace/Mosque, etc) Landmark (e.g. Near/Opposite a School/Church/Palace/Mosque, etc)

PART III: BANK ACCOUNT DETAILS (Please attach evidence of GH CEDI Bank Account)
Name of Bank

Account Holding Branch

Account/eZwich Number (13 or 16 digits)

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PART IV: ENDORSEMENT BY MISSION

Destination

Departure date

Name of Officer:

Designation: Signature & Stamp

PART V: EVIDENCE OF PERMANENT RELOCATION (To be completed in the absence of endorsement by Mission in PART IV)

In the absence of endorsement by my Home Mission in Ghana in Part IV above, I attach the following as evidence of my permanent
relocation from Ghana:

1. Permanent Emigration Declaration Form (SS-B11b)

2. A notarized copy of my Exit Travel Ticket (See page 3 of Form SS-B11b)
3. A notarized copy of Other Document (See page 3 of Form SS-B11b)

DECLARATION: I solemnly and sincerely declare that the facts stated above are true and complete to the best
of my knowledge and believe.

NB: Thumb prints can ONLY be taken by a SSNIT Officer

LEFT THUMB PRINT RIGHT THUMB PRINT

INDEX INDEX

In the 3
3 absence of a
thumb, tick
which finger
4 was used 4

5 5

Signature of Applicant Date

If the Applicant cannot read and write English, the following Jurat should also be signed:

I certify that this Application Form, before being signed by the Applicant was first audibly, clearly and distinctly read over and explained to him/her in
my presence and hearing and the said Applicant appeared perfectly to have understood same before making his/her mark hereto.

Name of Witness: Address:

Signature of Witness H/No.:

(FOR OFFICIAL USE ONLY)

Name of Benefits Officer

Officer’s Signature &

Stamp: Date

Branch Name Branch Code

Name of Branch Manager

Manager’s Signature
& Stamp: Date

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 SS-B11b
PERMANENT EMIGRATION DECLARATION FORM

IN THE SUPERIOR COURT OF JUDICATURE

IN THE HIGH COURT OF JUSTICE
ACCRA – GHANA A.D. …………

IN THE MATTER OF THE STATUTORY DECLARATIONS ACT OF 1971

(ACT 389)

IN THE MATTER OF A DECLARATION BY ……………………………………………………..

(Full name of Émigré)
OF ……………………………………………….. REPUBLIC OF GHANA TO AFFIRM MY
(Full address of Émigré)
PERMANENT EMIGRATION FROM GHANA

I, ………………………………………………………….…… of ………………………………………..……………….
(Full name of Émigré) (Address of Émigré)

Republic of Ghana hereby declare as follows: -

1. That I am the Declarant herein, a ……………………………… and a native of

(Profession of Émigré)

………………………, in the ………………………………….. and a ………………………. by birth

(Hometown of Émigré) (Geographical region/District/Province) (Nationality of Émigré)

and Nationality.

2. That I arrived in Ghana on ……….….. from ……………………… and upon being issued
(Date) (Location)
with Work Permit was employed by ………………………………………………………………….….
(Name of Employer)

from …………………….. to ………………………….

(Date of Commencement) (Date employment terminated)

3. That I understand that I am entitled to be paid the contributions I made to the Pension
Scheme under Act 766 as amended by Act 883 in Lumpsums only upon proof that I
am emigrating to my home country permanently.

4. That I therefore hereby affirm that I am emigrating to my home country of

…………………………….. on ……………………. with no intention of returning to Ghana

(Name of Émigré’s home country) (Date of departure)

again and that should I return to Ghana I will be mandated to contribute to the

Scheme but I will not be entitled to any benefits under Act 766 as amended by Act

883.

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 5. WHEREFORE, I make this solemn declaration sincerely and conscientiously in support
of the above statements and believing same to be true and correct by virtue of the
Statutory Declarations Act, 1971 (Act 389).

………………………………
(Name of Émigré)

DECLARED AT …………………. THIS

…..DAY OF……………………….., ……..

BEFORE ME

NOTARY PUBLIC

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LIST OF SUPPORTING DOCUMENTS TO BE PROVIDED IN FULFILLMENT OF
PERMANENT EMIGRATION AS PER SECTION 73(A) OF ACT 883

1. Permanent Emigration Declaration Form (SS-B11b) sworn by the Émigré in Ghana as

proof of permanent emigration.

2. Any one (1) of the underlisted Travel Documents notarized from the Émigré’s home
country. (Please tick one)

i. Passport
ii. Certificate of Permanent Residence
iii. Certificate of Naturalisation

3. Any one (1) of the underlisted Other Documents notarized in Ghana (Please tick
one)

i. Exit Visa
ii. Ticket (Exit Travel Ticket)
iii. Work Permit in Ghana
iv. Certificate of Permanent Residence in Ghana

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