Levy payment plan request form

If you'd like to apply to pay your levy by instalments complete the form below within 28 days of receiving your invoice.

Applicant Date Full name E-mail Contact telephone number

Position

Scheme name Address City/town Postcode PSR number Invoice number(s)

Who pays the levy? Sponsoring employers The Scheme with immediate reimbursement from a sponsoring employers Explain why there is an obligation on the sponsoring employer(s) to meet the cost of the levy immediately. Upload evidence below to support your explanation (for example, a schedule of contributions). Upload a cash flow forecast for the employer reconciled to bank accounts / comparative information from previous years. Please explain here why the forecast shows a repayment plan is necessary. Upload all supporting evidence here Over how many months are you requesting the levy payment be spread? Please explain why this is the quickest reasonable time frame

Explain why there are insufficient liquid funds in the scheme to settle the levy and why timely provision of liquid funds has not been possible. Attach evidence to support your statement (for example, a breakdown of scheme assets plus notice terms and evidence of unexpected calls on cash). Upload all supporting evidence here Over how many months are you requesting the levy payment be spread? Please explain why this is the quickest reasonable time frame

In accordance with section 195 of the Pensions Act, it is an offence to provide false or misleading information to the Board of the Pension Protection Fund. By signing this application you are confirming that the information provided is true and accurate to the best of your knowledge.