Local Government Pension Scheme

Nomination of beneficiary for
the payment of death grant

Please read the following notes before completing the form.

This form enables a member of the Local Government Pension Scheme to nominate a beneficiary or beneficiaries of any death grant payable in the event of their death. It must be witnessed at the time of signing by someone who is not a beneficiary.

Please note, a death grant isn’t payable if you’re aged 75 or over, if you have been receiving your pension for five years or more (if you retired between 1 April 1998 and 1 March 2008),
or if you have been receiving your pension for ten years or more (if you retired after
31 March 2008).

This form has space for you to nominate up to four beneficiaries. However, should you wish to nominate more beneficiaries please attach another form. Please ensure that any additional forms are also signed and witnessed, and that your total nominations equal 100%.

The nomination made on this form will be treated as not being in force at the time of the member’s death if a subsequent nomination form has been received.

If any part of the death grant has not been paid within two years of the date of death it will be paid to the member’s personal representatives (which may incur tax charges).

The nomination made on this form may be cancelled or amended by the completion of another nomination form.

Whether a nomination is made or not, the Pension Fund retains absolute discretion in respect of to whom the death grant is paid but takes due regard of any wish expressed by a member.

The detail on your nomination form can be viewed on your online record. Log in or sign up to our My Pension Online – Member Self Service system on our website. The online facility allows you to:

•	View and update personal details, including changing your address
•	View your service history, including any service which has been transferred
•	View your nominated beneficiaries

We will not normally send an acknowledgement of this form, but if you wish to receive one please state your email address:

1	Your details and declaration	

Titles		First name(s)		Address:	
Surname			
Date of birth			
NI number										Postcode:	
Name of employer		

2	Spouse / partner details                             (This will only be used in the event of bereavement)	

Forenames:	Surname:	
Email:	
Phone number:	

I have read and understood the notes above and hereby nominate the beneficiary or beneficiaries below to receive payment of any death grant payable in the event of my death.
I have signed below in the presence of the witness detailed below.

Signed:	Date:	

3	Witness details and declaration	

I declare that this form has been signed in my presence by the person detailed above.

Signed:	Date:	
Full name:	
Address:	
	Postcode:	

Beneficiary
Full name:	
Address:	
Date of birth:	Relationship to you (if any):	
Percentage share:		

Beneficiary
Full name:	
Address:	
Date of birth:	Relationship to you (if any):	
Percentage share:		

Beneficiary
Full name:	
Address:	
Date of birth:	Relationship to you (if any):	
Percentage share:		

Beneficiary
Full name:	
Address:	
Date of birth:	Relationship to you (if any):	
Percentage share:		

LPFA, Newham, Ealing, Havering, Brent & Bexley, Hammersmith & Fulham LGPS or Kent, London & Bedfordshire Fire please use:

LPPA
PO Box 1383
Preston
PR2 0WR

Lancashire LGPS, Lancashire Fire & Lancashire Police please use:

LPPA
PO Box 1381
Preston
PR2 0WP

Hertfordshire LGPS & Hertfordshire Fire please use:

LPPA
PO Box 1384
Preston
PR2 0WS

Cumbria LGPS, Cumbria Fire & Mersey Fire members please use:

LPPA
PO Box 1382
Preston
PR2 0WQ