Form AFPS Form 2
Q1. Intentionally left blank
Part A – Your Details
Q2. First Name
Part A – Your Details
Q3. Surname
Part A – Your Details
Q4. Address
Part A – Your Details
Q5. Postcode
Part A – Your Details
Q6. Email Address
Part A – Your Details
Q7. Service Number
Part A – Your Details
Q8. National Insurance Number
Part A – Your Details
Q9. Date of Birth (dd/mm/yyyy)
Part A – Your Details
Q10. Telephone Number
Part B – Nomination of Benefit
Q11. I wish to nominate my Death Benefit Lump Sum in the event of my death
Part B – Nomination of Benefit
Q12. I wish to nominate my Deferred Pension Lump Sum in the event of my death before the Deferred Pension Benefits come into payment
Part B – Nomination of Benefit
Q13. I wish to revoke any previous nomination and replace with that detailed below.
Q14. Part C – Nominee Details
Part C – Nominee Details
Q14a. Please note: Nominees must be an existing contact on JPA. Please add nominee(s) to your JPA contacts before submitting this form. To include additional nominees use the form at Part H.
Part C – Nominee Details
Q15. First Name
Part C – Nominee Details
Q16. Surname
Part C – Nominee Details
Q17. Address
Part C – Nominee Details
Q18. Postcode
Part C – Nominee Details
Q19. Relationship
Part C – Nominee Details
Q20. Organisation Nominated Percentage %
Part C – Nominee Details
Q21. Is this person your legal next of kin? Yes No
Options: Yes; No
Part C – Nominee Details
Q22. Is this person your additional nominee? Yes No
Options: Yes; No
Part C – Nominee Details
Q23. Is this nominee to be provided with communications from the Service Welfare Organisations? Yes No
Options: Yes; No
Q24. Part D - Data Protection
Part D - Data Protection
Q25. How the MOD collects and uses personal information
Q26. Part E - Declaration
Part E - Declaration
Q27. I confirm that • the information I have given is accurate and complete to the best of my knowledge and belief. • this supersedes any previous nomination that I have made.
Part E - Declaration
Q28. Remember – You must sign this form yourself if you can, even if someone else has filled it in for you. If a representative who acts as a Power of Attorney or Appointee for the claimant is signing this form, they must enclose evidence to show that they are the legal representative.
Q29. Part F - Consent for email correspondence
Part F - Consent for email correspondence
Q30. Veterans UK is happy to conduct correspondence with customers via a nominated email address if that is their preference. There are some types of personal information we would not be able to include in an email correspondence, which are listed below: • I authorise Veterans UK of the MOD to use email whenever possible in its correspondence with me via my nominated email address shown on the front of this claim form. I accept that the information may include my personal details excluding bank account numbers, National Insurance number, medical details and any other information that could compromise my identity. • I understand that correspondence transmitted by email may be open to abuse because it is transmitting over an unsecured network. I accept that the MOD will not be liable for any loss, interception or unauthorised use of information transmitted this way. I am content for Veterans UK to correspond with me from the email address shown at the front of this claim form.
Part F - Consent for email correspondence
Q31. Do you wish to correspond via email? Yes No
Options: Yes; No
Q32. Part G – Signature of Applicant
Part G – Signature of Applicant
Q33. I have I have not completed a continuation sheet
Part G – Signature of Applicant
Q34. Signature
Part G – Signature of Applicant
Q35. Date
Q36. Part H - Continuation sheet
Part H - Continuation sheet
Q37. PLEASE NOTE - THIS FORM MUST BE RETURNED BY POST. Copies received by e-mail will not be accepted
Part H - Continuation sheet
Q38. First name
Part H - Continuation sheet
Q39. Surname
Part H - Continuation sheet
Q40. Service Number
Q41. Part B – Additional Nominee Details
Part B – Additional Nominee Details
Q42. First Name
Part B – Additional Nominee Details
Q43. Surname
Part B – Additional Nominee Details
Q44. Address
Part B – Additional Nominee Details
Q45. Postcode
Part B – Additional Nominee Details
Q46. Relationship
Part B – Additional Nominee Details
Q47. Organisation nominated Percentage %
Part B – Additional Nominee Details
Q48. Is this person your legal next of kin? Yes No
Options: Yes; No
Part B – Additional Nominee Details
Q49. Is this person your additional nominee? Yes No
Options: Yes; No
Part B – Additional Nominee Details
Q50. Is this nominee to be provided with communications from the Service Welfare Organisation? Yes No
Options: Yes; No
Part B – Additional Nominee Details
Q51. First Name
Part B – Additional Nominee Details
Q52. Surname
Part B – Additional Nominee Details
Q53. Address
Part B – Additional Nominee Details
Q54. Postcode
Part B – Additional Nominee Details
Q55. Relationship
Part B – Additional Nominee Details
Q56. Organisation nominated Percentage %
Part B – Additional Nominee Details
Q57. Is this person your legal next of kin? Yes No
Options: Yes; No
Part B – Additional Nominee Details
Q58. Is this person your additional nominee? Yes No
Options: Yes; No
Part B – Additional Nominee Details
Q59. Is this nominee to be provided with communications from the Service Welfare Organisations? Yes No
Options: Yes; No