• Is there any other pay deemed pensionable via an APB (from 01/07/2013) i.e. Temporary Promotion? *
• No
• Yes - Total pension contributions relating to the 'Temporary payment' (Employee, Employer & Notional III Health percentages) from 1 July to date of leaving

Please provide annual rates of pay for the last 12 months in all cases:

Any pay treated as temporary for pension purposes should be excluded but pensionable elements such as FDA included. CPD is also excluded.

Date from (dd/mm/yyyy) Annual Pay £ Date from (dd/mm/yyyy) Annual Pay £ Date from (dd/mm/yyyy) Annual Pay £

Was pay higher in any of the earlier 2 years?

• No – Move onto next question
• Yes –
• Date from (dd/mm/yyyy) Annual pay £
• Date from (dd/mm/yyyy) Annual pay £
• Date from (dd/mm/yyyy) Annual pay £

Is/was the firefighter a retained member of one of the final salary schemes (1992, 2006, RDS Modified) *

• No – Move onto next question
• Yes –
• Actual pensionable pay for the previous complete financial year £
• Actual pensionable pay from 1 April to retirement date

Member made RDS modified election?

• No - Move onto next question
• Yes –
• Repaying by periodical payment? No/Yes
• No – Move onto next question
• Yes –
• Date of first payment(dd/mm/yyyy)
• Amount of monthly payment £
• Is the member continuing to make these periodic contributions after leaving? Yes/No

CARE Pay - for leavers from 1 April 2015 who are members of the 2015 scheme, you will need to provide pensionable pay received including APP treated as having been received.