Last date of service * Drop down calendar (dd/mm/yyyy)

Pay retirement benefits from Drop down calendar (dd/mm/yyyy)

Type of Retirement *

• Early (50/25) Maximum Lump Sum
• Early (50/25) Restricted Lump Sum
• Employer Initiated Retirement
• Ordinary (30 Years)
• Partial Retirement (2015 Scheme only) - Permanent Lower Tier III Health PLUS Injury on Duty
• Permanent Ill Health (Lower Tier)
• Permanent Ill Health (Upper Tier)
• Degree of disablement *
• Permanent Lower Tier Ill Health PLUS Injury on Duty
• Permanent Upper Tier Ill Health PLUS Injury on Duty
• Voluntary (Age 55)
• Degree of disablement*

• Permanent Upper Tier III Health PLUS Injury on Duty

• Degree of disablement *

Extra contributions - Were there any contributions outstanding at the date of leaving?

No – Move onto next question

Yes – Further question below

• Please give details of the outstanding contributions here £
• How are these arrears being recovered?

Please provide any strike information that has not yet been notified to WYPF.

• Date of strike (dd/mm/yyyy)
• Hours on strike
• Add another?
• Total number of days strike
• Strike contributions being repaid?
• No/Yes
• No/Yes

Please provide strike information based on strike only in the last 12 months up to the last day of employment/active membership.

• Total number of hours strike
• Pay lost due to strike £

Additional Pension Benefits*

• Was member in receipt of Long Service Increment (LSI) at 30 June 2007?
• Is member in receipt of CPD?
• No/Yes
• No
• Yes - Total pension contributions relating to the CPD payment (Employee, Employer & Notional III Health percentages) from 1 July to date of leaving £