Application
reference number
For office use only
*SFPLS0100F*
SMALL PENSION FUND
LUMP SUM PAYMENT REQUEST
for use with the Collective Retirement Account
For use by financial advisers only
Form purpose
This form can be used to request the payment of benefits under the small pension fund lump sum rules. Please refer to Important Information
below for more details.
Important notes for completion
• Please use BLOCK CAPITALS only and blue or black ink.
• Please ensure all applicable sections of the form are completed, as missing information will result in a delay in processing or the return of this
form.
• This form must be signed and sent to the following address:
Old Mutual Wealth, Old Mutual House, Portland Terrace, Southampton SO14 7AY
Important Information
• To take benefits under the small pension fund lump sum rules, you must have reached age 55.
• Up to £30,000 can be taken as small lump sums if the account is uncrystallised.
• The small lump sum must not exceed £10,000 within an individual arrangement within the Account. It must extinguish the entitlement to benefits
under the arrangement, and no more than two of this type of payment must have been received previously.
• If you wish to take between £10,000 and £30,000, it will be necessary for us to split your uncrystallised pension arrangements to allow a lump
sum payment to be made in accordance with the small pension fund lump sum legislation. If you have Enhanced Protection or Fixed Protection
2012 or 2014, the creation of a new arrangement could jeopardise these protections. Please consult your financial adviser if any of these
forms of protection apply to you.
• Up to £10,000 can be taken from crystallised accounts. This must extinguish the entitlement to benefits under this arrangement. Crystallised
funds cannot be split into multiple arrangements.
• The lump sum, except for 25% of any uncrystallised funds, is liable for income tax. We will deduct tax at the basic rate (20%). Depending on
your income tax position, this may result in an over-payment or under-payment of income tax. Details of the process can be found in our booklet
‘A guide to income tax and your pension’, available from your Financial Adviser or online at www.oldmutualwealth.co.uk/.
• The small pension fund lump sum payment value will be dependent on the value of your investment holdings at the time of receipt of all our
requirements.
• The amount of money you must retain in your account following any withdrawal is the greater of 10% of the entire fund value or
£1000 + 1.5 x any outstanding Phased Initial Charge.
1 ACCOUNT HOLDER DETAILS
Title
Mr
Mrs
Miss
Other u please specify
Surname
First name
Middle initial(s)
Address
Postcode
Date of birth
D D M M Y
National Insurance number
Y Y Y
Collective Retirement Account number
Evidence of age – please provide one of the following (or a copy certified by a professional person):
• your photocard driving licence
• your passport
(Your driving licence or passport must be valid and must not have expired.)
• your birth certificate
(If your name is currently different from your birth certificate, we will require evidence of the change of name – for example your marriage certificate or a change of
name deed.)
• a Confirmation of Verification of Identity (CoVI) from your financial adviser.
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2Financial Adviser Statement –
this statement must be completed in order for Old Mutual Wealth to
carry out the instruction on behalf of the client
This is to confirm that I have provided my client with advice and discussed the appropriate risks in relation to this transaction.
Financial Adviser Name
Firm Name
Signature
Date
D D M M Y
Y Y Y
3 SMALL PENSION FUND LUMP SUM DETAILS
Please confirm the number of Small Pension Fund Lump Sums you have previously received:
None
One
Two
Please confirm the amount you would like to take as a Small Pension Lump Sum, up to the value of £30,000
£
,
.
Please note: Where you are applying for more than £10,000 under the Small Pension Fund Lump Sums legislation this will involve multiple Small
Pension Fund Lump Sums being used. No more than three Small Pension Fund Lump Sums can be paid to you in total, including any
previous Small Pension Fund Lump Sums indicated above. Where, for any reason, the monetary value applied for exceeds the number
of such payments we are able to make, we will only pay the maximum allowed by legislation under the Small Pension Fund Lump Sum
regulations.
4 BANK/BUILDING SOCIETY
Please confirm your bank/building society details (payment will be made via BACS)
Name of account holder
Bank/building society name
Branch address of bank/building society u this must be a UK bank/building society account.
Postcode
Account number
Sort code
–
–
Building society roll number u if applicable.
NOTE: Before we can make the payment, we need to see proof of the bank account ownership. The proof can be a voided
cheque or a copy of your bank account statement (certified as a true copy by your financial adviser). If you have online bank account
statements, a printed copy certified by your adviser will suffice.
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5 DECLARATION
• I declare that each small lump sum payment does not exceed £10,000, and extinguishes the entitlement to benefits under each of the arrangements.
• I confirm that this information about the number of small pension fund lump sums previously received by me is correct.
• I confirm that I wish to take the value confirmed above as a lump sum, or such lower amount as Old Mutual Wealth are able to pay under Small
Pension Fund Lump Sum payment legislation..
• I understand that all the lump sum, except for 25% of any uncrystallised funds, is liable for income tax.
• I understand that Old Mutual Wealth will deduct income tax from the lump sums described in this form.
• I understand that I am obliged to contact HM Revenue & Customs (HMRC) to claim a repayment of income tax for which I was not liable or to
account for any further income tax that may be due.
• I declare that payment by Old Mutual Wealth Life & Pensions Limited of the benefits under this Account shall constitute a full discharge from all
liabilities and claims arising from this transaction.
• I confirm that the information supplied by me is true to the best of my knowledge. I understand that any false statement may result in HMRC taking
legal action against me.
• I understand that if this is the first time I have taken a payment from this account, I have 30 days from the date payment is made by Old Mutual
Wealth in which to cancel this transaction. If I do so I will return all money received in respect of this account to Old Mutual Wealth and instruct
which pension plan it is to be placed into. I will not be able to reinstate this account. I understand that I can cancel this transaction by writing to
Old Mutual Wealth at their Southampton Office.
*SFPLS0100X*
Account holder’s signature
Date
D D M M Y
Y Y Y
www.oldmutualwealth.co.uk
Calls may be monitored and recorded for training purposes and to avoid misunderstandings.
Old Mutual Wealth is the trading name of Old Mutual Wealth Limited which provides an Individual Savings Account (ISA) and Collective Investment
Account (CIA) and Old Mutual Wealth Life & Pensions Limited which provides a Collective Retirement Account (CRA) and Collective Investment Bond (CIB).
Old Mutual Wealth Limited and Old Mutual Wealth Life & Pensions Limited are registered in England and Wales under numbers 1680071
and 4163431 respectively. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom.
Old Mutual Wealth Limited is authorised and regulated by the Financial Conduct Authority. Old Mutual Wealth Life & Pensions Limited is authorised
by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Their Financial Services register numbers are 165359 and 207977 respectively. VAT number 386 1301 59.
When printed by Old Mutual this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from
controlled sources and virgin fibre sourced from well managed, sustainable forests.
PDF8205/216-0064/January 2016
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