I.
Annex V
Widows and Orphans Pension Scheme/Surviving Spouses' and Children's Pensions Scheme
ELECTION FORM D
Departmental SerialTM No.
D
(To be completed in triplicate by a widowed/divorced contributor who wishes to discontinue contributing to WOPS/SSCPS)
To: Director of Accounting Services
via
(Head of Department)
I became a *widow/widower/divorcee/with pensionable child(ren)/without pensionable child(ren) on
. A G.F. 47* is attached herewith/has been submitted/will be submitted.
I hereby elect to discontinue contributing to the *Widows and Orphans Pension Scheme: Surviving Spouses' and Children's Pensions Scheme with effect from the date shown above.
I understand and accept that this election is irrevocable.
Signature of
Witness
Name in
BLOCK LETTERS
Hong Kong I.C. No.
Date
Signature
Name in
BLOCK LETTERS
Hong Kong I.C. No.
TRN
Date
(Day) (Month)
(Year)
II. To: Director of Accounting Services
I have returned the triplicate copy of this form to the officer for his retention.
"Delete as appropriate
Distribution
Original to be forwarded to the Treasury Duplicate - to be retained by the Department Tnplicate to be returned to the applicant G.F. 564D
for (
Date
(
(Head of Department)
}