TNAG-2667-FCO40-3864-Hong-Kong-Civil-Service-1993 — Page 165

1.

Annex

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

ELECTION FORM D

Departmentai Serial 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 Triplicate to be returned to the applicant

G.F. 564D

{

for (

(Head of Department)

Date

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