If Faxing please ensure Employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No._________________
HR 113 V2 November 2018 Page 4 of 4 25/01/2019
Declaration under Section 51 of the Public Service Pensions (Single Scheme and
Other Provisions) Act 2012
To be completed by persons availing of Critical Illness Protocol as a member of a Public
Service Pension Scheme in Ireland with a commencement date on or after July 28
th
2012.
Please indicate if any of the following apply
1) Are you in receipt of any Retirement Benefit(s) or any Preserved Yes No
Pension / Lump Sum from any Irish Public Service Pension Scheme?
2) Are you entitled to receive any Retirement Benefit(s) or any Preserved Yes No
Pension / Lump Sum from any Irish Public Service Pension Scheme?
If you have answered yes to either (1) and/or (2) above, please complete details hereunder and
furnish a copy of any supporting documentation which you have received from any previous Irish
Public Service employers.
Irish Public Service Pension Benefit in Payment / Preserved Public
Service Pension Benefit Entitlement
Description (Benefit Type) e.g.
Current/Preserved Occupational
Pension and/or Retirement Lump Sum
Annual Gross Pension Value
Annual Preserved Pension Value
Number of Years of Accrued
Pensionable Service
I hereby declare that the information provided above is complete and correct.
Signed: ___________________________ Name: _____________________________
(Block Capitals)
PPS No:*__________________________ Date: ______________________________
*If you have more than one PPS Number, please provide all of your PPS Numbers.
Critical Illness Protocol
Declaration