COVID-19 impact notification

If you've been adversely impacted by COVID-19 and would like to apply for an extension of your payment terms please complete the form below

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? The Scheme The Scheme with immediate reimbursement from a sponsoring employers Please explain why there is an obligation on the sponsoring employer(s) to meet the cost of the levy immediately Please explain how COVID-19 has negatively impacted your business

Please explain how COVID-19 has negatively impacted your scheme

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.