Application for Scheme Retireme nt Benefits Fully completed applications must be received by HSC Pension Service 3 months before intended date of retirement To be completed by the applicant You must complete Parts 1-9 of this form and take it to your employer who will complete the remaining parts. If you are a Principal GP, Salaried GP or Locum GP, following completion of Parts 1-9, please forward directly to HSC Pension Service at the address on page 11. Dental Practitioners should forward their completed forms (Sections 1-9) to Dental Payments Office, BSO, 2 Franklin Street, Belfast BT2 8DQ If you have any diff iculty completing this form you should contact your employer. Please complete in black ink using CAPITAL letters. IMPORT ANT - Expected Date of Retirement Please insert the date you expect to retire from HSC Employment in order to ensure the priority of your application can be assessed Part 1 Personal details 1 Surname 2 Forename(s) (in full) 3 Maiden name (if applicable) 4 Date of birth (your employer will need to see your birth certificate) 5 Title (tick correct box) 6 National Insurance number Dr Mr Mrs Miss Ms 7 Your present address 8 Where is your present place of employment (Location, HSC Trust/HSC Board etc) --------------------Postcode --------------------- ---------------------Postcode -------------------- 9 Your da ytime telephone number 10 Home email address
Part 2.1 - Status Please provide appropriate documentation in order that your employer can verify the details in Part 2. 11 What is your partnership status? (tick the appropriate box) Married Sing le W idowed Divorced Civil-partner Dissolved CP Survivor CP Nominated Partner* 12 If you are / were married, please give the date of your marriage 13 If you are in a registered civil partnership, please give the date of your registered partnership 14 If you are a widow / w idower, surviving partner, please give the date of your wife s / husband s / partner s death 15 If appropriate, please give the date when your divorce was granted / civil partnership dissolved. 16 Your spouse or civil partner s full name 17 Your spouse or civil partner s date of birth 18 Your spouse or civil partner s National Insurance number * If you have scheme membership on or after 1 April 2008 you can apply for your nominated partner to receive a survivor pension after your d e a t h by completing the form PN1, which is available from the website or by contacting HSC Pension Service.
Part 2.2 Dependant Children 19 If you die and leave dependant children, an allowance may be payable from the Scheme. Have you any dependant children? Yes Give details below No Surname and other names Gender Date of Birth Part 3 Allocation of Pension A guide for pensioners and their dependants gives advice about allocating part of your pension. It also explains how to apply to do this. 20 If you wish to allocate part of your pension for the benef it of a dependant, please tick this box and attach your completed form AW6/11 A f rom the guide Part 4 Additional Voluntary Contributions These are- MP AVCs - Money Purchase Additional Voluntary Contributions FS AVCs - Free Standing Additional Voluntary Contributions 21 Have you ever, or are you contributing towards an Yes complete the details below MP AVC / FS AVC plan No go to Part 5 Name of MP AVC/ FS AVC provider Address of MP AVC/ FS AVC provider ---------------------------- Policy number ---------------------------- ---------------------------- -------------------------------------------- Post code ------------------------
Part 5 HM Revenue and Customs (HMRC) information To comply with HMRC legislation please read Tax Section of A Guide for Pensioners and their Dependants and then answer the following questions: 22 Have you any retirement arrangements outside the Yes please continue HSC Pension Scheme, whether in payment or not. This includes money purchase AVCs, but excludes the State Retirement Pension? No go to question 26 23 Will your annual pension from all your pension Yes arrangements, including the HSC Pension Scheme, be more than 60,000 per year? Don t k now please continue No go to question 26 24 Have you taken any pension benef its on or after Yes 6 April 2006? No a. Total aggregated percentage of LTA used % b. Date of f irst benef it crystallisation event 25 Have you taken any pension benef its before Yes 6 April 2006? No Gross annual rate of pension in payment on today s date or at date at 24b If you are unable to provide us with answers to question 24 and 25, we will only be able to process your application if we treat your HSC Pension Scheme benef its as entirely in excess of the LT A. This will mean the scheme paying 55% of your lump sum and 25% of your pension directly to HMRC If you would like us to do this, please tick this box Alternatively please wait until you know what percentage of the LTA has been used bef ore returning this form. You may need to contact the Scheme Administrator of your other pension arrangements for this. 26 Have you any valid certificates from HMRC that Yes Attach copy of certificate either enhance your LTA or provide you with enhanced or fixed protection? No Certificate Number Enhancement type Enhancement factor Protected lump sum Value ( ) Valid enhanced protection certif icate number
Part 6 Lump Sum Choice Final Salary 1995 2008 Sections 27a Do you want an additional lump sum by Yes continue below No go to Part 7 giving up part of your pension? If YES do you want the maximum additional lump sum permitted? Yes go to question 28 No continue below Additional lump sum of (This is in addition to your normal lump sum) (whole pounds only) CARE 2015 Section 27b Do you want a lump sum by Yes continue below No go to Part 7 giving up part of your pension? If YES do you want the maximum lump sum permitted? Yes go to question 28 No continue below Lump sum of (whole pounds only) If Yes to question 27a/b, have you or are you due to receive any tax free cash from any Yes No other pension provider as at your retirement date? Part 7 - Continuing employment or re-employment in the Health Service (IMPORTANT: - See Declaration at Part 9 of this form & the section on re-employment in the Guide for Pensioners and their Dependants ). This includes employments in NHS England &W ales, Scotland or the Isle of Man. Continuing Employment / Re Employment 28 Are you still continuing in another HSC/NHS employment? No Yes complete question 30 Note: benef its may not become payable until you leave all your HSC/NHS employments.) 29 Do you intend to take up a new HSC/NHS employment after you retire? No go to Part 8 Yes complete question 31 on next page If you are a GP and have answered No at 28 or 29, please confirm your date of retirement to gms.claims@hscni.net. This will ensure that no over payment of seniority occurs. Continuing Emplo yment 30 Please give below details of any HSC posts you are continuing in after this emplo yment. Name of employer Address of employer Band/Grade Number of hours worked
Re-employment after retirement 31 Please give below details of an y new HSC/NHS post(s) you intend taking up after this retirement, (including NHS employment in England,W ales, Scotland or the Isle of Man) Name of Employer Address of Employer ----------------------- ----------------------- ----------------------- ------------------------------- Post code ----------------------------- Grade Number of hours Worked Date of commencement Part 8 Payment Details (if you live outside the UK please contact HSC Pension Service) 32 Please pay m y pension and lump sum to my- Bank (please tick) Building Society Name of Account Holder Name of Bank / Building Society Branch address ----------------------- ---------------------- ----------------------- --------------------------------- Post code ----------------------------- Bank sorting code (This is the 6 figure number) Bank Account number Building Society Roll No.
Part 9 Declaration to be signed and dated by all applicants 33 I declare that I am retiring f rom HSC employment. I conf irm that I have read the scheme guidance A guide for pensioners and their dependants. I understand that it is my responsibility to inform HSC Pension Service of any re-employment in the HSC/NHS in order to minimise the possibility of a potential overpayment of benef its. I understand that, if I have retired on normal age grounds, my pension MAY BE SUSPENDED if I return to HSC/NHS employment within one month. Work in the HSC/NHS totaling 16 hours or less a week is ignored for this purpose. If I have chosen to retire early, (except on VER actuarially reduced ) and return to HSC/NHS employment bef ore age 60 then my pension can be suspended or abated depending on my earnings. It is my responsibility to monitor my earnings if I wish to avoid any overpayment I understand that I will have to pay back any overpayment of pension that occurs due to any re employment and failure to do so may result in ref erral to the Counter Fraud and Probity Unit within the Business Services Organisation. I confirm that I have read the Guidance relating to Recycling of Pension Commencement Lump Sums (PCLS) and understand my obligation in notifying HSC Pension Service if I recycle my HSC PCLS. If I have Fixed Protection I declare I have checked for Benefit Accrual (Note 2 on the Certif icate for Fixed Protection refers) and have not had Benefit Accrual up to and including the date of my retirement. I declare that the information I have given is correct and complete to the best of my knowledge and belief. I hereby agree to notify HSC Pension Service immediately of any changes to the inf ormation provided at time of application. I apply f or my Scheme retirement benefits. If MEDICAL or DENT AL practitioner last day of Pensionable Service Signature Date / _/ SMS TEXT MESSAGING SERVICE HSC Pension Service has now implemented a NEW Text Messaging Service. Pensioners should join this service to receive important updates on information relating to their pension. To join this service text HSCPENSIONS to 67300. Note: This initial text message will incur a one off charge based on your network operator s standard text message rate. However, all subsequent text messages sent from HSC Pension Service will be free of charge. To end your HSC Pension Service text alerts membership text STOP to 67300.
To be completed by the Employer Part 10 Retirement details 1 Name 2 National Insurance number 3 Date of birth Has their date of birth been verified bysight of birth certificate? Yes No (If nothebirthcertificatemustbe forwardedtohscpensionservice) 4 Where relevant, has their marriage/civil partnership been verified b y sight of certificate? Yes No N/ A 5 Where relevant, has divorce/civil partnership dissolution been verified b y sight of certificate? Yes No N/ A Please note: If the above documentation has not been verified the employer should request sight of said documentation from the employee. 6 Pa yroll indicative 7 Scheme 1995 2008 2008 Optant 2015 8 Last day of scheme membership (Account should be taken of leave due and untaken at date of retirement.) 9 Type of retirement Age 1 Incapacity 2 Premature (redundancy, interests of the efficiency of the service) 3 (if 3, ensure a cop y of the Departmental Approval Form is attached where appropriate) VER (Actually reduced) 4 VES (Voluntary Exit Scheme) 5
Part - 11 Total pensionable/reckonable pa y This employment is - full-time complete boxes (i), (ii) (if applicable), (iv) and (v) part-time sessional complete boxes (i), (ii) (if applicable), (iii), (iv) and (v) complete boxes (i), (ii) (if applicable), (iii), (iv) and (v) Detail provided at (i) below should be the notional whole time equivalent f or part time staff. For 1995 Section members, please provide rates and total pensionable pay for the last four years for final pay control assessment. The best of the last three years figure will be used for pension calculation purposes. Do not include domiciliary fees, they should be shown in box (ii) below. If the member s pensionable pay has increased by more than CPI+4.5% in any of the 3 years prior to their last day of service, the employer will be liable for a f inal pay control charge. T he pension application will NOT processed until all required information is received so that an assessment can be carried out. Please refer to Final Pay Controls and Employer Charge Factsheet on our website: For 2008 Section and Optants give reckonable pay f or all relevant years (f rom1april 2008 to be the earliest). (i) Year 1 From to am ount Year 2 From to amount Year 3 From to amount Year 4 From to amount Year 5 From to amount Year 6 From to amount Year 7 From to amount _ Year 8 From to amount Year 9 From to _ amount Year 10 From to amount
(ii) Domiciliary f ees (iii) Part-time staff only Actual total pensionable pay f or last 3 years 1995/2008 Scheme Year 1 Year 2 Year 3 (iv) Annual rate of pay at cessation _ (v) If total pensionable pay and annual rate of pay differ by more than 10%, please provide written explanation For 2015 Scheme Actual Pensionable Pay required f rom: 1. The 1 April 2015 to the 31 March 2016 2. The beginning of the current financial year to date of leaving. (1 st April to date of leaving) Leaving date - _ Part 12 Pre-dispatch check list and certification (i) Incapacity retirement - (ii) Premature retirement - Do not send AW6 until you have received confirmation letter from HSC Pension Service that member accepted for ill health pension benefits Copy of Departmental Approval Form attached (iii) All retirements - SD 55A/B terminating is attached (tick relevant box) - was sent on /_ /_
Certification of earnings details I certifythat (i) The amounts shown in Part 11 are reconciled with the pension contributions payable. (ii) All scheme contributions have been, or will be, paid to the HSC Pension Scheme within the regulatory timef rame. Signature Date Position Tel No Emplo ying Authority or GP Practice Stamp This form should be forwarded to: HSC Pension Service Waterside House 75 Duke Street Londonderr y BT47 6FP Contact Telephone Number: 028 71319111