Form Flexibly accessed pension payment: repayment claim
About you
Q1. Title
Guidance: For example Mr, Mrs, Miss, Ms or Dr
About you
Q2. Your surname or family name
About you
Q3. Your first name
About you
Q4. Your address
Guidance: Postcode
About you
Q5. Your contact telephone number
About you
Q6. Best time to contact you
About you
Q7. Your date of birth DD MM YYYY
About you
Q8. Your National Insurance number
About you
Q9. Your employer PAYE reference number
Guidance: Example 123/A246
Employment income
Q10. Do you expect to receive income from paid employment during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 11. If Yes, fill in the table below
Employment income
Q10a. Employer Expected amount of Do you receive taxable Total estimated amount income from employer benefits from this of taxable benefits before tax employer (Yes/No)
Self-employment income
Q11. Do you expect to receive any profit from self-employment during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 13. If Yes, go to question 12
Self-employment income
Q12. Total amount of profits
UK pension income
Q13. Have you or do you expect to receive income from any UK pension during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 14. If Yes, fill in the table below
UK pension income
Q13a. Pension payer’s full name and address Full amount of any UK pension income you expect to receive before tax is taken off Details of pension flexibility payments paid as lump sums Do not include any non-taxable element of the payment Name of pension company making the flexibility payment Tax deducted Taxable lump sum
Taxable state benefits
Q14. Do you expect to receive any taxable state benefits during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 15. If Yes, fill in the table below
Taxable state benefits
Q14a. Name of taxable state benefit Full amount of any taxable state benefits you expect to receive before tax is taken off
Taxed interest on UK savings and investment income
Q15. Do you expect to receive taxed interest on UK savings and investment income during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 18. If Yes, go to question 16
Taxed interest on UK savings and investment income
Q16. Total amount of savings interest (before tax)
Taxed interest on UK savings and investment income
Q17. Total tax paid
Untaxed interest on UK savings
Q18. Do you expect to receive untaxed interest on UK savings during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 20. If Yes, go to question 19
Untaxed interest on UK savings
Q19. Total amount of untaxed interest you expect to receive
Dividends from UK companies
Q20. Do you expect to receive dividend income from stocks and shares in the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 22. If Yes, go to question 21
Dividends from UK companies
Q21. Total amount of dividend income
Any other income
Q22. Do you expect to receive any other income in the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 23. If Yes, fill in the table below
Any other income
Q22a. Source of any other income Full amount of other income you expect to receive
Gift Aid payments
Q23. Do you expect to make any Gift Aid payments in the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to ‘How we’ll make your repayment’. If Yes, go to question 24
Gift Aid payments
Q24. Total amount of Gift Aid payments you expect to make in the tax year you are claiming for You should include regular payments and any one-off payments
Gift Aid payments
Q25. Total amount of one-off Gift Aid payments Total amount of one-off Gift Aid payments included in question 24
How we’ll make your repayment
Q26. Who would you like us to make a repayment to?
Options: You (go to question 27 to 30); A nominee (go to question 31 to 36)
Guidance: Your account details
How we’ll make your repayment
Q27. Name on account
How we’ll make your repayment
Q28. Bank or building society name
How we’ll make your repayment
Q29. Sort code
How we’ll make your repayment
Q30. Account number
Your nominee’s details
Q31. Nominee’s name
Your nominee’s details
Q32. If your nominee is your tax advisor, please enter their reference
Your nominee’s details
Q33. Nominee’s address
Guidance: Postcode
Your nominee’s details
Q34. Bank or building society name
Your nominee’s details
Q35. Sort code
Your nominee’s details
Q36. Account number
Declaration
Q37. I can confirm that the information on this form is correct and complete to the best of my knowledge and belief.
Declaration
Q38. Full name
Declaration
Q39. Daytime telephone number (including area code)
Declaration
Q40. Signature
Declaration
Q41. Date DD MM YYYY
Declaration
Q42. If you’ve signed on behalf of someone else, tell us the capacity in which you’re signing this form
Guidance: Claims can be made by: • the person authorised by the courts to look after the affairs of a mentally incapacitated adult (or the Department for Work and Pensions appointee) • an attorney authorised by an ordinary or general power of attorney. Tell us if you’ve signed the form as either: • Administrator • Executor • Power of Attorney • Receiver • Trustee
About you
Q1. Title
Guidance: For example Mr, Mrs, Miss, Ms or Dr
About you
Q2. Your surname or family name
About you
Q3. Your first name
About you
Q4. Your address
Guidance: Postcode
About you
Q5. Your contact telephone number
About you
Q6. Best time to contact you
About you
Q7. Your date of birth DD MM YYYY
About you
Q8. Your National Insurance number
About you
Q9. Your employer PAYE reference number
Guidance: Example 123/A246
Employment income
Q10. Do you expect to receive income from paid employment during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 11. If Yes, fill in the table below
Employment income
Q10a. Employer Expected amount of Do you receive taxable Total estimated amount income from employer benefits from this of taxable benefits before tax employer (Yes/No)
Self-employment income
Q11. Do you expect to receive any profit from self-employment during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 13. If Yes, go to question 12
Self-employment income
Q12. Total amount of profits
UK pension income
Q13. Have you or do you expect to receive income from any UK pension during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 14. If Yes, fill in the table below
UK pension income
Q13a. Pension payer’s full name and address Full amount of any UK pension income you expect to receive before tax is taken off Details of pension flexibility payments paid as lump sums Do not include any non-taxable element of the payment Name of pension company making the flexibility payment Tax deducted Taxable lump sum
Taxable state benefits
Q14. Do you expect to receive any taxable state benefits during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 15. If Yes, fill in the table below
Taxable state benefits
Q14a. Name of taxable state benefit Full amount of any taxable state benefits you expect to receive before tax is taken off
Taxed interest on UK savings and investment income
Q15. Do you expect to receive taxed interest on UK savings and investment income during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 18. If Yes, go to question 16
Taxed interest on UK savings and investment income
Q16. Total amount of savings interest (before tax)
Taxed interest on UK savings and investment income
Q17. Total tax paid
Untaxed interest on UK savings
Q18. Do you expect to receive untaxed interest on UK savings during the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 20. If Yes, go to question 19
Untaxed interest on UK savings
Q19. Total amount of untaxed interest you expect to receive
Dividends from UK companies
Q20. Do you expect to receive dividend income from stocks and shares in the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 22. If Yes, go to question 21
Dividends from UK companies
Q21. Total amount of dividend income
Any other income
Q22. Do you expect to receive any other income in the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to question 23. If Yes, fill in the table below
Any other income
Q22a. Source of any other income Full amount of other income you expect to receive
Gift Aid payments
Q23. Do you expect to make any Gift Aid payments in the tax year you are claiming for?
Options: No; Yes
Guidance: If No, go to ‘How we’ll make your repayment’. If Yes, go to question 24
Gift Aid payments
Q24. Total amount of Gift Aid payments you expect to make in the tax year you are claiming for You should include regular payments and any one-off payments
Gift Aid payments
Q25. Total amount of one-off Gift Aid payments Total amount of one-off Gift Aid payments included in question 24
How we’ll make your repayment
Q26. Who would you like us to make a repayment to?
Options: You (go to question 27 to 30); A nominee (go to question 31 to 36)
Guidance: Your account details
How we’ll make your repayment
Q27. Name on account
How we’ll make your repayment
Q28. Bank or building society name
How we’ll make your repayment
Q29. Sort code
How we’ll make your repayment
Q30. Account number
Your nominee’s details
Q31. Nominee’s name
Your nominee’s details
Q32. If your nominee is your tax advisor, please enter their reference
Your nominee’s details
Q33. Nominee’s address
Guidance: Postcode
Your nominee’s details
Q34. Bank or building society name
Your nominee’s details
Q35. Sort code
Your nominee’s details
Q36. Account number
Declaration
Q37. I can confirm that the information on this form is correct and complete to the best of my knowledge and belief.
Declaration
Q38. Full name
Declaration
Q39. Daytime telephone number (including area code)
Declaration
Q40. Signature
Declaration
Q41. Date DD MM YYYY
Declaration
Q42. If you’ve signed on behalf of someone else, tell us the capacity in which you’re signing this form
Guidance: Claims can be made by: • the person authorised by the courts to look after the affairs of a mentally incapacitated adult (or the Department for Work and Pensions appointee) • an attorney authorised by an ordinary or general power of attorney. Tell us if you’ve signed the form as either: • Administrator • Executor • Power of Attorney • Receiver • Trustee