Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697630449778.pdf (Antigua and Barbuda)
MEDICAL BENEFITS SCHEME DECLARATION Name: _______________________________________________________________ Registration Number: ___________________________________________________ Type of Business if (changed): ____________________________________________ Address:______________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Telephone Number: _____________________________________________________ Statement for the year 20_________________________________________________ Attachments (please list here if applicable) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ I …………………………………………..…….
declare the above information to be true and correct (please print) …………………..…………….... …………………………..…….. Signature Date MEDICAL BENEFITS SCHEME Self -Employed Statement of Acknowledgement Re Declaration Name of Self-Employed: ___________________________________________________________ MBS Registration #: ___________________ Previous MBS Registration #: ________________ Type of Business: ____________________________ Contact Numbers: ____________________ Address: _________________________________________________________________________ Declaration Period: ____________________ Monthly Earnings: __________________________ I ……………………………….…………….
hereby acknowledge that I have not provided any financial documentation to substantiate my declaration for the specific period.

I ………………………………………..……... further acknowledge that the Medical Benefits Scheme Representative explained that for all future declarations, I must provide all requisite financial records to substantiate my submission.

Failure to submit financial records to substantiate my submission will result in MBS assessing my monthly contributions.
NB: It is a contravention of the MBS ACT 2010, Part II Section 36, to provide false information to the Medical Benefits Scheme.

Any such person is liable on summary conviction to a fine of three thousand dollars ($3,000.00) and to imprisonment for one (1) year.
_________________________________ __________________________ ___________________ Name of Self-Employed (print) Signature Date Official Use Recommendations/Comments:……………………………………………………………………… ………………………………………………………………………………………………………… ……………………………………………….………………………………………………………...

Processed By: ……………..………………………………..

Date: ………………………….……….

Comments:…………………………………………………………………………………………… ………………………………………………………………………………………………………… Verified by: ……………………………………………… Date: …………………………………..