MAMURU-RWOMPO CBO

NEXT OF KIN & BENEFICIARY DECLARATION FORM

SECTION A: MEMBER DETAILS

Full Name:
National ID No.:
Phone Number:
Email Address:
Postal/Physical Address:

SECTION B: NEXT OF KIN DETAILS

Full Name:
Relationship:
National ID No.:
Phone Number:
Address:

SECTION C: BENEFICIARY DETAILS

Full Name Relationship National ID No. Signature

SECTION D: DECLARATION
I hereby declare that the information provided above is true and accurate to the best of my
knowledge. I understand that the Next of Kin listed is for contact purposes and the Beneficiaries
listed are entitled to receive benefits in accordance with the policies of Mamuru-Rwompo CBO and
applicable laws in Kenya.

Chairman Name: Signature: Date:

Secretary Name: Signature: Date:
Treasurer Name: Signature: Date: