Levy payment plan request form

Applicant for payment plan

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 employer(s)

The Scheme, with immediate reimbursement from a sponsoring employer(s)

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).

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

Click to upload evidence

You can upload as many files as needed, up to a limit of 100MB.
To remove a file, tick the box next to it and click 'Remove'.

Over how many months are you requesting the levy payment be spread? Please explain why this is the quickest reasonable time frame

Over how many months are you requesting to spread your levy payment?

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.