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Pensions Declaration Ref PD1
AS PROVIDED FOR UNDER SECTION 787R(4) OF THE TAXES CONSOLIDATION ACT 1997 ( FOR
THE PURPOSES OF DISCLOSING BENEFIT CRYSTALLISATION EVENTS OCCURRING PRIOR TO
THE CIVIL SERVICE OR PUBLIC SERVICE PENSION ENTITLEMENT CURRENTLY BEING CLAIMED)
1. Did you become entitled, on or after 7th December 2005, to any pension,
annuity, lump sum or any other pension related benefit, other than your pension
entitlements under your Public Service Pension Scheme currently being claimed?
(Please Tick as appropriate)
YES
2. Did you direct that a payment or transfer be made to an overseas pension
arrangement?
YES
3. Prior to
, or on, the date of your retirement from the Public Health Service or
the date of commencement of pension payment, do you expect to become
entitled to any pension, lump sum or any other pension related benefit (other
than the benefits arising from this Public Health Service Pension Scheme)?
YES
4. Do you intend to direct that a payment or transfer be made to an overseas
pension arrangement?
YES
5. If you have answered YES to any of the above questions, please
(a) Input in ascending order the sequence in which payment of benefit in respect of each pension
arrangement will occur for all Pension Benefit Arrangements AND
(b) Complete the attached Form PD 1(a) (noting that a separate PD1(a) form must be completed for
each separate Pension Benefit)
Type of Pension Arrangement
Payment
Sequence
Type of Pension Arrangement
Payment
Sequence
HSE Occupational Pension Scheme Retirement Annuity Contract
Defined Benefit Personal Retirement Savings
Account
Defined Contribution Other: Please Specify
AVC for purposes of supplementing
retirement benefits
6. Do you have a certificate from the Revenue Commissioners stating the amount
of your Personal Fund Threshold(PFT) in accordance with section 787P of the
Taxes Consolidation Act 1997?
If 'Yes', please enclose a copy of the Certificate issued by the Revenue
Commissioners
YES
Employee Declaration
I declare that the information provided by me in this form is complete and correct and hereby
personally accept any tax liability that may arise due to my non-declaration/incorrect declaration of
any pension benefits on this form.
Full Name (Block Capitals):
____________________________________________
PPS No:
_________________________
Address:
_____________________________________________________________________________________
Signature:
____________________________________________
Date: