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
Location
Personnel
No.
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)
Effective
Date
Last day of
service
Date Of
Birth
PPS No.
Section 2. Reason for Leaving. Please () Tick one
Resignation Tendered
Suppression of Post (without immediate payment
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
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
pay.