HSE Leaving Form – HR106
Please complete form in Block Capitals/Tick appropriate boxes.
HR 106_V4 Jan 2019
Page 1 of 3
Revised 25/01/2019
This form is completed by employees who are leaving the Health Service Executive.
Please forward the form to your HR/Personnel Administration Department for processing
Section 1. To be completed by the employee
Surname First Name
Work e-mail address: ________________________________@hse.ie
PC Login Name _______________________________________
List of applications used
My last day of service is my final working day. (Effective date is inclusive of Annual Leave due or exclusive of
Annual Leave overtaken)
Last day of
Date Of
Section 2. Reason for Leaving. Please () Tick one
Resignation Tendered
Suppression of Post (without immediate payment
of pension entitlements
Family Reasons
Dismissal (To be completed by Line Manager/ HR)
Further Training / Education
Voluntary Redundancy (without immediate
payment of pension entitlements)
Going Abroad
End of Contract
Death* (To be completed by Line Manager/ HR)
Personal Reasons
End of Training
No Promotional Opportunities
Unsuitable Hours
Other reason
If Other Reason Please specify:
Exceeds retirement age – with no entitlement to pension benefits (Not a member of HSE pension schemes)
NB! If reason for leaving is retirement please complete Retirement HR Form 107(a)
Section 3. Pension Contributions
If you are paying pension contributions and you have less than
pensionable service with the
Health Service Executive, you may receive a refund of your pension contributions, net of income tax in accordance
with the Taxes Consolidation Act, or alternatively you can opt to have your pension contributions retained towards
future service reckonability, should you be re-employed by the Health Service Executive/Public Service/Local
State Sector.
Please tick the appropriate box.
I request a refund of my pension contributions, net of income tax
I request that my pension contributions be retained for the future
If you opt to have a refund of your pension contributions it is your responsibility to ensure that we are
advised of the correct address for correspondence as this amount is normally paid separately to your final
If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the
Name ____________________________ Personnel No._________________
HR 106_V4 Jan 2019
Page 2 of 3
Revised 25/01/2019
Section 4. Correspondence Address (for receipt of written communications from
the HSE)
Street Address:
County Post Code Country
Phone No: Mobile Phone No:
Section 5. Bank Details
Note: Any change of bank details can only occur on the first day of any pay period. Please contact your payroll section for details of when
change may be effective from. It is your responsibility to ensure the change has been completed on payroll before making any
amendments to your old or new bank account (e.g. Cancel or set up of standing orders / direct debits, closing old account etc.)
Bank Name Bank address:
Bank Sort Code: Account Number
Bank Indentifier Code (BIC)
International Bank
Acc No. (IBAN)
Payee Name:
Section 6.Employee Declaration
I declare that the above information is accurate and correct on the date indicated below. I authorise my employer to
recover any monies owing by me from my final pay
Signature: Date
Section 7 – 10. To be completed by the Line Manager
Section 7. Objects on Loan (if Applicable)
Please list HSE property items on loan below. (e.g. Laptop, Mobile Phone, Keys, travel pass etc.)
Line Managers
Date of Return
Have Items on loan been recovered Yes No
If no, please ensure that items are recovered before the employee departs.
Section 8. Leave Details
Please Note any compensation payment for leave not taken during employment
must be adjusted in Payroll in advance of the leaving date (No Exceptions)
Leave Due to the Employee
Leave Entitlement
Leave Taken
Hours Due
Annual Leave (Confirmed)
Public Holidays (Confirmed)
If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the
Name ____________________________ Personnel No._________________
HR 106_V4 Jan 2019
Page 3 of 3
Revised 25/01/2019
Section 9. Recovery of monies Owed by employee
Please ensure that you notify payroll of any monies owing from the employee
Leave owed by the employee
Leave Entitlement
Leave Taken (Hours) Leave Overtaken (Hours)
Annual Leave (Confirmed)
Public Holidays (Confirmed)
Does Employee owe monies for Payroll Rationalisation Technical
Adjustment in 2004?
Yes No N/A
Has Payroll details been updated to take account of Technical
Adjustment recovery?
Yes No N/A
Does employee owe monies to HSE under Free Fees Initiative (FFI)
Yes No N/A
Has interim payment been ceased? Yes No N/A
Section 10. Line Managers Declaration
1. I confirm that I have notified payroll in relation to the recovery of monies as outlined above
2. I declare that the above information is accurate and correct.
Signature: Date:
Contact Tel No: e-mail Address:
Decision Number (if applicable)
Section 11. Hospital Manager/HR Manager Declaration
Signature Date
Contact Tel No: e-mail address:
Section 12. To be completed by Human Resources, Personnel Administration
System updated by: Date
Section 13. Payroll Interface (SAP Phase 1 only)
Superannuation schemes delimited Employment Signal Entered
Leave date Entered
Org. Assignment: Position Employment
Level 0%
Signed: Date
Section 14. Payroll Section
Name: Date:
Signature: Payroll Area:
Contact Telephone No: E-Mail:
Section 15. Circulation List
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