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[ ] Pension scheme

REQUEST FOR TRANSFER OF BENEFITS

Name:_______________________________________

Date of Birth: __________________________________

Membership Number:___________________________

National Insurance Number: _____________________

Company Name: ______________________________

Address:______________________________________

Date of Joining the Scheme: _______________________

Date of Leaving: ________________________________

To the Trustees of the [ ] Pension Scheme (the ‘Scheme’).

I hold benefits in the Scheme and I wish to apply to transfer the value of those benefits from the Scheme as set out below. This includes any benefits which would be payable from the Scheme to my dependants or beneficiaries in the event of my death.

I confirm that I have received a statement of entitlement in respect of my benefits in the Scheme which shows the cash equivalent transfer value (CETV) of my benefits as at my guarantee date.

I wish to transfer my benefits to the following Receiving Arrangement(s):

Name of Receiving Arrangement:___________________________________

Address of Receiving Arrangement:___________________________________

HMRC Registration Number:_______________________________________

DECLARATIONS

Decision to transfer out

1. •

   The decision I have made to transfer my benefits to the Receiving Arrangement is my own, and I have not received any advice from the Scheme or from the Trustees of the Scheme (the ‘Trustees’).