If Faxing please ensure Employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No._________________
HR 114b July 2014 Page 3 of 3 23/06/2015
Declaration under Section 51 of the Public Service Pensions (Single Scheme and
Other Provisions) Act 2012
To be completed by persons availing of a Temporary Rehabilitation Remuneration 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
Yes No
1) Are you in receipt of any Retirement Benefit(s) or any Preserved
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
Paying Authority
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.