NHS Superannuation Scheme (Scotland) APPLICATION FOR LUMP SUM ON DEATH AND WIDOW(ER)’S/PARTNER’S PENSION DEATH IN SERVICE Before completing the claim form please read the guidance notes at the back of the application. Further information and guidance on Death and Family Benefits is available on our website at www.pensions.gov.scot Please complete all relevant fields of the application form as incomplete information will delay your application. Section 1 - DECEASED MEMBER’S DETAILS Scheme reference number Surname Forename(s) Title Dr Mr Mrs Miss Ms National Insurance number Date of birth / / Date of death / / Marital Status Single (never married) Married or Civil Partnership Divorced or Dissolved Civil Partnership Widowed AW7 2021 V1.0 Other Section 2 – APPLICANTS INFORMATION. RELATIONSHIP TO THE DECEASED Spouse* Civil Partner Date of Marriage/Civil Registration / / Surviving Partner Nominee Legal Personal Representative * There is no eligibility for a widow(er)’s pension if the applicant was estranged from the member and in a co-habiting relationship with another party Section 3 - APPLICANTS DETAILS Surname Forename(s) Title Dr Mr Mrs Miss Ms National Insurance number Date of birth / / Contact Address Post Code Contact Number Email Address Marital Status Single (never married) Married or Civil Partnership Divorced or Dissolved Civil Partnership AW7 2021 V1.0 Other Widowed Section 4 – APPLICANTS BANK DETAILS Name of account holder Name of Bank/Building Soc. Branch & Address Post Code Bank sort code Account Number Building Society roll Number (If applicable) Bank Account type Current Account Deposit Account Spouse/Civil Partner Applications - Go to Section 9 Unmarried Partner Applications - Continue through Sections 5-8 Nominee/Legal Personal Representative - Go to Section 9 AW7 2021 V1.0 UNMARRIED PARTNERS APPLICATIONS ONLY Section 5 – ABOUT YOU AND YOUR PARTNER How long had you and your partner lived together? Years Months (see personal checklist part 3) Were you living together at the time of your partner’s death? Yes No If No, give details of why you were living apart and where you were living on a separate sheet and send with the application Had the deceased ever been married to or been in a Civil Partnership with a previous partner? Yes No Have you ever been married to or been in a Civil Partnership with a previous partner? Yes No If Yes, provide copies of all relevant Divorce Decree absolute(s), Dissolution of Civil Partnership(s) or previous partner’s Death Certificate(s). UNMARRIED PARTNERS APPLICATIONS ONLY SECTION 6 – ABOUT YOU AND YOUR PARTNER’S FINANCIAL CIRCUMSTANCES Did you and your partner have any of the following joint financial arrangements. Joint mortgage or tenancy Yes No Joint bank account Yes No Were you beneficiaries of each other’s wills? Yes No Were you beneficiaries of each other’s life assurance? Yes No Did you and your partner share any other joint financial commitments not shown in the above list? Yes No SEE SECTION 7 for evidence requirements AW7 2021 V1.0 UNMARRIED PARTNERS APPLICATIONS ONLY Section 6 (cont) Please give any other information about you and your partner’s financial arrangements that would support your claim. For example, whether you shared day-to-day living expenses and whether you are experiencing additional expense following your partners death (continue on a separate sheet if necessary) UNMARRIED PARTNERS APPLICATIONS ONLY Section 7 - SUPPORTING EVIDENCE REQUIREMENTS As well as the standard evidence required (see Section 9), unmarried partner applications must come with evidence of: Cohabitation - A Mortgage Statement, Tenancy Agreement or Council Tax Statement in Joint names This must show that both parties were cohabiting for at least two years prior to the death of the member Financial Interdependence - A Joint Bank Account If there is no joint bank account separate bank accounts for both member and applicant as long as the addresses on the statements are the same and are dated at least two years prior to the death of the member up to a point within eight weeks of death Marital Entitlement - Divorce Certificates or Death Certificates of previous spouses AW7 2021 V1.0 Miscellaneous - Additional evidence to support your application Shared Utility Bills (landline phone, gas, electricity, water), Wills, Life Assurance UNMARRIED PARTNERS APPLICATIONS ONLY Section 8 – CONFIRMATION- TICK AL

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