As part of the application process, you must provide a colour copy of a Government issued valid photo ID plus a photo of you holding the ID. Your face and the ID must be clearly visible in the image.

Please upload a recent household bill or bank statement showing your name and residential address.

Checks will be paid to the Applicant named above. No third-party checks will be issued.

Please provide the date your refund was given and the name of the plan administrator that provided the refund.

I own the pension plan and/or local retirement product identified in this application. I hereby apply to Freisenbruch Insurance Services for a Small Pension refund for the amount set out in this application.

I certify that on the date I sign this Certification:

• I am 65 years or older.
• I have not been required by any third party to make this application.
• All the information supplied in this application and any documents that accompany this application is accurate to the best of my knowledge.
• I understand that if I do not provide information in this application which is true, accurate and complete, the plan administrator will refuse to refund the requested amount.

You should read the authorisation and, if you agree to the terms set out, sign and date the authorisation in the appropriate place at the bottom of the authorisation. If you do not sign the authorisation as required, this application will be deemed incomplete.

The authorisation will not be valid for the purposes of this application if you sign the authorisation prior to the Temporary Pension Refund of Money under the National Pension Scheme (Refund) (Temporary) Regulations 2020’s original effective date or within 30 days of the signed application being received by Freisenbruch Insurance Services.

Authorisation

I authorize Freisenbruch Insurance Services to contact the Pension Commission, any other person including other pension plan administrators or local retirement product administrators to confirm or verify any information provided by or about me in this application.

I hereby authorize the Pension Commission, other pension plan administrator or local retirement product administrator to provide information to Freisenbruch Insurance Services with respect to information necessary for this application in order to assist Freisenbruch Insurance Services in understanding and verifying their authenticity.