TNAG-2667-FCO40-3864-Hong-Kong-Civil-Service-1993 — Page 163

I.

Annex IV

Widows and Orphans Pension Scheme/Surviving Spouses' and Children's Pensions Scheme

ELECTION FORM C

(To be completed in triplicate by a single/widowed/divorced contributor, or a female contributor, who wishes to discontinue contributing to WOPS/SSCPS)

To: Director of Accounting Services

via

(Head of Department)

I declare that as at

1.2.1993

(the date of implementation) I remained a

*bachelor/widow/widower/divorcee/with pensionable child(ren)/without pensionable child(ren).

I hereby elect to discontinue contributing to the Widows and Orphans Pension Scheme/Surviving Spouses' and Children's Pensions Scheme and to receive a refund of my contributions, if any, in accordance with the terms of Civil Service Branch Circular No. 4/93.

I understand and accept that this election is irrevocable.

Signature of

Witness

Name in

BLOCK LETTERS

Hong Kong L.C. No.

Date

Signature

Name in

BLOCK LETTERS

Hong Kong I.C. No.

TRN

Date

C

(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

Triplicate G.F. 564C

Duplicate to be retained by the Department

to be returned to the applicant

(

for (

Date

(Head of Department)

)