Test Form

AW6 TEST

Step 1 of 10

Section Break
To be completed by the applicant:
- You MUST complete Part 1-9 of this form. Once submitted, it will go 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 by selecting HSC Pensions as the employer in the drop down below
- Dental Practitioners should complete a manual form available in the HSC scheme forms section of our website, and forward their completed forms to Dental Payments Office, BSO, 2 Franklin Street, Belfast, BT2 8DQ.
- If you have any difficulty completing this form, you should contact your employer directly
Please indicate your proposed date of retirement*
Who is your current/most recent employer*
Part 1 - About Yourself
Please enter details about yourself including your contact telephone number and email address, if you have one. You must show your original birth certificate or an original certified copy of it to your employer. If you do not have an original birth certificate you may show them your original passport.
Name*
Prefix First Name Surname
Former Surname (if applicable)
National Insurance Number*
Present Address*
Street Address Address Line 2 City County Post Code Country
Contact telephone number*
Personal email address*
Date of Birth (your employer will need to see your birth certificate)*
Please show your birth certificate to your employer by submitting it along with this form using the upload button below. If your birth certificate is not available, show another official document, such as a passport, instead.
File
Max. file size: 20 MB.

Part 2 - About your Status
Part 2.1: It is important that you tell us your current status and supply details of your spouse or civil partner, if you have one. This information is used in the event of your death and informs us if there are any survivor’s benefits payable if you die before your spouse or civil partner. Having these details will speed up the payment of any survivor’s benefits due and will also put less strain on your dependants at that time. We ask you to show various certificates and other papers to your employer.
What is your Partnership status? (tick the appropriate box)*
- Single (Not previously married)
- Married
- Civil Partnership
- Divorced/Dissolved Civil Partnership
- Widowed/Survivor Civil Partnership
* 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 death by completing the form PN1, which is available from the website or by contacting HSC Pension Service.
If you are/were married, please give the date of your marriage

Day
Month
Year
If you are in a civil partnership, please give the date of your registered partnership

Day
Month
Year
If you are a widow/widower or surviving partner, please give the date of your wife's/husband's/partner's death

Day
Month
Year
If appropriate, please give the date when your divorce was granted/civil partnership dissolved

Day
Month
Year
Your spourse or civil partner's full name
Prefix First Last
Your spouse or civil partner's date of birth
Your spouse or civil partner's National Insurance number
Please provide appropriate documentation in order that your employer can verify the details in Part 2.
Max. file size: 20 MB.
e.g. a marriage certificate
2.2 Dependent Children: If you die and leave any dependent children, a children's pension may be payable from the Scheme. (Please read the Pensioners and Dependents section.)
A children’s pension may be payable on your death. The terms ‘children pension’ and ‘child’ can cover a number of other possible dependants as well as your own children – see below for more information.

Where your Scheme membership extends beyond 31st March 2008 a pension may be paid if the child is dependent on you, both at retirement and on your death, and they are:

•Under age 23, or

•Aged 23 or over and incapable of earning a living due to a permanent physical or mental infirmity which he/she was suffering at the time of your death

Where your Scheme membership ended before 1st April 2008 a pension may be paid if the child is dependent on you, both at retirement and on your death, and they are:

•Under age 17, or

•Aged 17 or over but still in full time education or training and have been so continuously since the age of 17until they reach a maximum age of 23, or

•Aged 23 or over and incapable of earning a living due to a permanent physical or mental infirmity which he/she was suffering at the time of your death.

“Child” can include:

•Biological children;

•Children of your civil partner or nominated qualifying partner;

•Step children and adopted children;

•A brother, sister, nephew or niece of you, your spouse, civil partner or nominated qualifying partner;

•A grandchild;

•A half-brother, half-sister, step brother or step sister of you, your spouse, civil partner or nominated qualifying partner

•Children born before and within 12 months of the date you left the scheme with deferred benefits
Have you any dependant children?*
Enter the details of any qualifying children in the boxes.
- Yes (Give details below)
- No
Surname Forename Gender Date of Birth

Part 4 - Additional Voluntary Contributions
Additional Voluntary Contributions form part of your overall Lifetime Allowance total. In order for HSC Pension Service to notify your AVC provider of the Lifetime Allowance accrual from our scheme, we require as much information requested on this form.
4.1 Have you ever, or are you contributing towards an MP AVC/FS AVC plan*
These are:
MP AVC's - Money Purchase Additional Voluntary Contributions

FS AVC's - Free Standing Additional Voluntary Contributions
- Yes - Complete part 4.2 below
- No - go to Part 5
4.2 AVC Provider Details
Name of MP AVC/FS AVC provider
Address of MP AVC/FS AVC provider
Street Address Address Line 2 City County Post Code Country
Policy Reference Number

Part 7 - Employment Details
If you are claiming benefits from the 1995 Section you normally have to have stopped working in the HSC for at least 24 hours before you can become entitled to receive them. Your pension, under the 1995 Section, may be suspended if you return to HSC employment (including a Direction Body/Independent Provider) within one calendar month. Work in the HSC totalling 16 hours or less a week is ignored for this purpose. Exceptions are where you have deferred pension under the 1995 Section and current membership under the 2008 Section or 2015 Scheme or, you are drawing down some of your 2008/2015 benefits. In these cases it is not necessary to have stopped working in the HSC for at least 24 hours before becoming entitled to receive your deferred 1995 Section benefits.

Returning to work following Ill Health Retirement:

If you are receiving a Tier 2 Ill Health Pension, in certain circumstances, if you return to work your pension benefits may be affected. Our website provides more detailed information on how your pension may be affected. It is important that you read this factsheet and make yourself aware of restrictions for those members who have retired on a Tier 2 ill health pension.

If, following payment of your Tier 2 Ill Health Pension you have returned to work with any employer, which includes employment outside the HSC, you should inform HSC Pension Service immediately of the dates of your re-employment and the details of your earnings.
7.1 Have you any other work in the HSC at the time of retirement from this job?*
- Yes
- No
7.2 Will you be employed in the HSC after retirement from this job?*
- Yes
- No
If you ticked YES at 7.1 or 7.2 above, please tell us below about the work you will be doing
Where do you work, or where will you be working?
What is your job or what will your job be?
Will the work at 7.1 continue after you retire?
- Yes
- No
On what date will any work at 7.2 above begin?

Part 8 - Payment Details
Please enter the details of the Bank or Building Society where you would like your benefits to be paid. Your benefits will only be paid into a bank or building society account, as this is the safest method of payment. Complete this section fully to ensure HSC Pension Service can arrange payment of your benefits.

If your bank account is outside the UK, payments can be made direct, providing it is one of the countries listed in the Retirement Guide and it is capable of receiving secure electronic payments of funds. You will need to complete the mandate for the payment to be made to an overseas bank and submit it to HSC Pensions. This is available by contacting HSC Pension Service directly on 028 71 319111 (option 1).
8.1 Bank/Building Society account details
Name(s) of Account Holder(s):
Branch Sort Code (6 Digits):*
Account Number (8 Digits):*
and/or Building Society Roll Number:
Full Name and Address of your Bank/Building Society
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If your bank is outside the UK, please indicate which country your pension will be paid to below:
Country

You will need to complete a TAPS mandate form for benefit payments to be made to an overseas bank account and attach it to this application. Please contact HSC Pension Service directly to retrieve relevant form.

Part 9 - Declaration
You must read the declaration below before clicking confirm.

You must read the Retirement Guide and any associated factsheets if you are unclear on any of the points in this section. Information on the recycling of pension commencement lump sum is available on the ‘Guide for pensioners and their dependants’.
• I declare that I am retiring from HSC Employment
• I confirm 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 potential overpayment of benefits
• 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 totalling 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 before 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 reemployment, and that failure to do so may result in a referral 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 Sum (PCLS) and understand my obligation in notifying HSC Pension Service if I recycle my HSC PCLS
• If I have fixed protection, I declare that I have checked for Benefit Accrual (note 2 on the Certificate 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 information provided at the time of application
• I apply for my Scheme retirement benefits
If MEDICAL or DENTAL practitioner please state last day of pensionable service
Confirm*
I have read the above points, and agree that all information provided within this form is accurate to the best of my knowledge

Test Form

AW6 TEST

Step 1 of 10

Section Break

Part 1 - About Yourself

Part 2 - About your Status

Part 3: Allocation of Pension

Part 4 - Additional Voluntary Contributions

Part 5 - HM Revenue and Customs (HMRC) Information

Part 6 - Retirement Lump Sums

Part 7 - Employment Details

Part 8 - Payment Details

Part 9 - Declaration

Survey

Surname	Forename	Gender	Date of Birth