The Local Government Pension Scheme Election to …

1 The Local Government Pension Scheme Election to opt-outSurname: Employer:Address:Post code:Job title:Signed:Date:Dorset County Pension Fund, County Hall, Dorchester, Dorset, DT1 1XJ Telephone: 01305 224845 Fax: 01305 224049 Email: Website: should only complete this form if you do not wish to become or remain a member of the Local Government Pension Scheme . If you complete this form within the first 3 months of taking up employment, this Election will take effect from the first day of that employment and you will be refunded any contributions that you have paid so far. However, if you complete this form after the first 3 months of membership, this Election will take effect from the start of the next pay period following the date you signed this form (unless a later date is specified) and your benefits will be deferred until retirement, or you choose to transfer to another Pension arrangement. To ensure that your Election to opt-out is processed as efficiently as possible, please complete all details below and return the form to your employer.

2 Failure to do so will delay the date on which your opt out can be :Tel. number:Job titlePlace of workContracted hours If you have more than one job please indicate if this Election is for all employments; All employmentsDate of birth:Specific employment only (please specify which job/s by using the table below)Forename(s):I hereby give notice to terminate my membership to the Local Government Pension Scheme at the earliest opportunity, having been made aware of and considered the full implications of my actions (please see overleaf). I wish to opt out of Pension saving I understand that if I opt out I will lose the right to Pension contributions from my employer I understand that if I opt out I may have a lower income when I retire NI Number:Sex: M / FIt is very important that you consider carefully any decision to opt-out of the Scheme . Your employer cannot ask you or force you to opt out. If you are asked or forced to opt out, you can tell the Pensions Regulator - see If you change your mind, you may be able to opt back in - write to your employer if you want to do this.

3 If you stay opted out, your employer will normally put you back into the Pension Scheme in around three years. If you change your job, your new employer will normally put you back into the Pension Scheme straight away. If you have another job, your employer might also put you into Pension saving, now or in the future. This notice only allows you to opt out of Pension saving with the employer, or employers, you name overleaf. Please remember that the Scheme currently provides the following benefits: o Secure benefits o Spouse's / Civil partner's pensions o Pension on retirement o Nominated cohabiting partner's pensions o Inflation proof pensions o Dependant's allocated pensions o Employer contributions o Children's pensions o Early retirement benefits o Tax free cash option on retirement o Ill health Pension o Tax relief on contributions o Death in service benefits The Pensions Section is willing to arrange the provision of individual estimates of the benefits payable as they currently stand and at your earliest retirement date.

4 If you elect to leave the Scheme and are continuing in employment you may be entitled to either; a refund, transfer value or preserved benefit. Please contact the Pensions Section for further details of the options available to you. Please note that if you have already transferred Pension rights into the Scheme , you will not be eligible for a refund of contributions even if your membership is less than 3 months. Contributions are subsidised by reduced National Insurance contributions and tax relief. The amount deducted on your payslip is not the amount you would gain by opting out. Always remember to take independent financial advice before you make a final decision. Your union's Pension advisor, an accountant or a recognised financial service may be able to help. If you require any further information please visit: or alternatively you can contact the Dorset County Pension Fund on: Telephone: 01305 224845 Email: you need to know Notes of guidance for employees wishing to leave the SchemeCommencement date:FT EQ pay:Contractual hours: Unique Employment No.

5 :Effective date of opt out:Refund paid:Yes / NoAuthorised by:Date:For HR / Payroll use