Retirement Form – HR107 (a) v1.

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Purpose : This form is to be used when you are retiring from the HSE and making application for payment of
Pension Benefits. It is to be initiated by the employee. It is important that you complete this form correctly and
forward it to your line manager.
To Be Completed by Employee
Title Mr. Mrs. Ms. Miss Prof. Dr. Rev. Fr. Sr. Please () Tick one

First Name: Surname:

Pension Personnel
D D M M Y Y Y Y
Start Date Number
Date Of
D D M M Y Y Y Y PPS No.
Birth
Gender Male Female

Contract Officer Non Officer

Former Health Board/ Area Name

Service Area / Hospital Name

Employed as / Grade

Reason for Retirement

Reached Minimum Retirement Age Reached Compulsory Retirement Age

Permanent Infirmity Job Sharing Retirement Initiative

Cost Neutral Early Retirement Early Retirement Scheme Nurses

Correspondence Address (for receipt of written communications from the HSE)

Street Address:

Town/City

County Postcode Country

Phone No (Landline): Mobile Phone No:

Personal Email Address:

Bank Details (confirm details of account you wish your benefits to be paid to)
Bank Name Bank Branch

IBAN No:
Name of
BIC Account.
Please contact bank branch or review bank statements to obtain the above information. Failure to provide
completed correct information may delay payment of your benefits.

HR107 (a)_v1.3 November 2013 Page 1 of 6

 If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the form
Name __________________________ Personnel No. _________________________

Additional Personal Details

Marital Single Married Registered Divorced Separated Widowed Other
Status Civil Partnership
If Other please Specify:

If you are widowed/divorced please provide death certificate/decree absolute.

Please specify Birth Name (Maiden Name) if applicable:

Date of
Spouses Name: Marriage/Registered D D M M Y Y Y Y
Civil Partnership

Dependant Children Details

Children (including adopted children) under age 22 and any Incapacitated/Child Dependents over 22 years of age

Children’s Names Date of Birth

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

Third Party Payroll Deductions

The following deductions will be facilitated by the HSE National Pensions Payments office and deductions will be
arranged by the HSE National Pensions Payments office accordingly. Please tick any deductions you currently
have through your salary which you would like to continue from your pension.

VHI You must supply your VHI policy number:

Hospital Saturday Fund

New Ireland Assurance

Irish Life Assurance

The following deductions can be taken from your pension however you are required to contact the relevant
companies directly once you receive your first pension payment quoting your new pension/personnel number
from your pension payslip.
AXA insurance Please call 1890 600 600

Health Service Staff Credit Union Please call 1890 677 864

Laya Healthcare(New Group Number 24508) Please call 1890 700 890

Aviva Heathcare Please call Hennelly Finance 091-586500

The above third party companies are the only deductions which may be facilitated through your pension by HSE
National Pensions Management. If you have a deduction currently taken from your payslip which is not listed and you
wish to continue paying after retirement please contact the appropriate organisation/company directly.

HR107 (a)_v1.3 November 2013 Page 2 of 6

 If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the form
Name __________________________ Personnel No. _________________________

Employee Declaration
I declare that the above information is accurate and correct on the date indicated below. I undertake to notify the
relevant authority of any changes to this information by completing the appropriate form.

Signature: Date D D M M Y Y Y Y

To be completed by Line manager

Name (please Print):

Signature: Date: D D M M Y Y Y Y

Grade:

Contact Tel No: E-mail Address:

Decision Number (If Applicable):

To be completed by General Manager/ Assistant National Director of HR

Name (please Print):

Signature: Date: D D M M Y Y Y Y

Grade:

Contact Tel No: E-mail Address:

HR107 (a)_v1.3 November 2013 Page 3 of 6

 Section 51 Pension Benefits
Declaration
Declaration under Section 51 (Duty to make declarations etc.) of the Public
Service Pensions (Single Scheme and Other Provisions) Act 2012.
To be completed by persons applying for a Public Service Pension Benefit.
Please note that your retirement benefits cannot be finalised and paid until a
completed Declaration Form has been received.
Please indicate if any of the following apply (Specify Yes or 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

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 Irish Public

Service Pension Benefit Entitlement other than the HSE benefit to which
this HR107 application relates
Description (Benefit Type)
e.g. Current/Preserved Occupational
Pension and/or Retirement Lump Sum
Annual Gross Pension Value €

Annual Preserved Pension Value €

Paying Authority

3) Are you in receipt of remuneration (earnings) from any other Irish

Public Service Body apart from the HSE ?

If you have answered Yes to (3) above, please complete details hereunder and furnish
a copy of your contract of employment with the relevant Irish Public Service Body.
Remuneration (Earnings)
Description (Contract Type)

Annual Gross Pay (Earnings)

Paying Authority (Per payslip)

I hereby declare that the information which I have provided above is complete and accurate.

Signed:___________________________ Name:_____________________________
(Block Capitals)
PPS No:*__________________________ Date:______________________________
*If you have more than one PPS Number, please provide all of your PPS Numbers.
HR107 (a)_v1.3 November 2013 Page 4 of 6
 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 YES NO
entitlements under your Public Service Pension Scheme currently being claimed?
(Please Tick as appropriate)

2. Did you direct that a payment or transfer be made to an overseas pension YES NO
arrangement?

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 YES NO
entitled to any pension, lump sum or any other pension related benefit (other
than the benefits arising from this Public Health Service Pension Scheme)?

4. Do you intend to direct that a payment or transfer be made to an overseas YES NO

pension arrangement?
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 Type of Pension Arrangement Payment
Sequence 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? YES NO
If 'Yes', please enclose a copy of the Certificate issued by the Revenue
Commissioners
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:
____________________________________________

HR107 (a)_v1.3 November 2013 Page 5 of 6

 Pensions Declaration Form Ref PD1(a)
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)
Please use separate sheet for each Pension Arrangement (if applicable):

1. Type of Pension Arrangement Defined Benefit

Defined Contribution
(A PD1(a) is not required for the HSE pension Additional Voluntary Contributions for
to which this HR107 application relates)
Purposes of supplementing retirement benefits
Retirement Annuity Contract
Personal Retirement Savings Account (PRSA)
Overseas Pensions Arrangement
Other
Please Specify:_____________________
2. Name of Scheme Provider:
3. Contact Details for Scheme Administrator:

4. Policy or Reference Number:

5. Date of Entitlement to Benefits: DD/MM/YYYY
6. Amount of any transfer payment to an Overseas
Arrangement & Contact Details for the Receiving € __________________
Pension Arrangement Contract _________________
7. If a DEFINED CONTRIBUTION/AVC/PRSA
arrangement, the value of the fund on the date of benefit € __________________
entitlement
8. If a DEFINED BENEFIT arrangement, the
a) Amount of Annual Pension € __________________
b) Amount of any Lump Sum € __________________
c) Factor used for calculating the capital value of
the pension __________________
d) The Amount or Market Value of any assets
transferred by exercise of 'ARF/PRSA Option' € __________________
9. May we contact the scheme administrator(s) on your behalf
for the purposes of clarifying if necessary, any aspect of the
information provided by you under this declaration? YES NO
You should note that that there is provision in the legislation that, where the capital value of an individual’s
pension benefits exceed the Standard Fund Threshold/PFT, tax due on any chargeable excess may be
deducted from the individual’s lump sum or ongoing pension.
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:

HR107 (a)_v1.3 November 2013 Page 6 of 6