Third party declaration
/This declaration form is to be completed by someone who wishes to be appointed as trustee of a pension scheme in order to distribute benefits on behalf of the scheme’s sole remaining member.
Please note, under section 80(1)(c) of the Pensions Act 2004, any person who knowingly or recklessly provides The Pensions Regulator with information which is false or misleading in a material particular is guilty of an offence. Upon conviction, a person guilty of the offence is liable to a fine and/or imprisonment.
Your details
Pension scheme name:Your full name:
Have you been known by any other names previously? If so, please state them here.
Your address:
Your date of birth:
Your email address:
Only provide this if you consent to receiving electronic correspondence and notices from The Pensions Regulator
Member’s full name:
What is your relationship to the scheme member?
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Have you ever been:
/Please answer Yes or No
1. / The subject of any criminal proceeding involving dishonesty or deception, which has been brought against you and has not yet been concluded, or have you ever been convicted of a criminal offence involving dishonesty or deception?2. / Declared bankrupt or been subject to the appointment of an official or administrative receiver in the last five years?
2a. / Has this disqualification been waived?
3. / Disqualified from being a director of a company by order made under the Company Directors Disqualification Act 1986? Or have you ever been subject to an order made under section 429(2)(b) of the Insolvency Act 1986 (failure to pay under County court administration order)?
4. / Entered into a Deed of Arrangement (Deed of Trust in Scotland) in favour of creditors which you have not been discharged from?
5. / Disqualified or suspended from being a trustee of an occupational pension scheme, or have you been removed as trustee of a trust scheme by an Order made by the High Court or the Court of Session?
6. / Are there any factors which may affect your capacity to act as a trustee; such as, have you ever been subject to an order under the Mental Capacity Act 2005 or proceedings under the Mental Health Act 1983?
Please ensure you attach any documentation that supports the statements in this
declaration form.
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I declare that:
- I have answered all questions fully and accurately to the
best of my knowledge and belief. - I will notify The Pensions Regulator promptly of any changes
in the information provided. - I give consent to The Pensions Regulator to make any
investigations as considered appropriate by them.
- I have authority to act on behalf of the member and have attached:
proof of the member’s consent to act on their behalf.
- I am not and have not been disqualified from being a trustee of an
occupational pension scheme.
Your signature:
Date:
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