Kestrel International (USA) Inc.

There is no charge to you for us to do this research. The information is confidential. Should we find money in your pensions, we will recommend the best approach for your investments. Please give as much information as you can to allow us to thoroughly research your application. On completion, please print and sign the form at the bottom and fax to: (813) 258-5902.

Full Name

Maiden/married name at time of employment in UK:

E-mail Address

How did you hear about us?

*Please give your current address*
Address
City	State/Province ZIP/PC Country

*Please give your last address in the United Kingdom*
UK Address	City/Town PC
When did you cease to be a UK tax resident? National Insurance Number

Daytime Phone		Your date of birth
Home Phone		Home Fax
Best time to contact you		Work Fax

Did you belong to a UK Occupational Scheme? If yes, please provide details below


1. EMPLOYER'S NAME
Address
City/Town	Postal Code Country


No of years with employer What years were you employed
Was the scheme contributory or non contributory?
Do you know the value of your pension fund?
(If YES, state the valuation and date of valuation)


2. EMPLOYER'S NAME
Address
City/Town	Postal Code Country


No of years with employer What years were you employed
Was the scheme contributory or non contributory?
Do you know the value of your pension fund?
(If YES, state the valuation and date of valuation)


3. EMPLOYER'S NAME
Address
City/Town	Postal Code Country


No of years with employer What years were you employed
Was the scheme contributory or non contributory?
Do you know the value of your pension fund?
(If YES, state the valuation and date of valuation)

Did you have a personal pension arrangement or make voluntary contributions (AVC or FSAVC)
Were you contracted out of SERPS
Are you interested in applying for your 25% tax free lump sum (if you are 50 years of age or older)

Authorisation
To: Name of Company
Address
(If you have a personal pension from a life insurance company please provide the policy number).
To: Additional Company
Address
To: Additional Company
Address
This is to authorise you to provide Kestrel Pensions Administration Ltd/Kestrel International USA Inc., with all information they require in respect of my UK preserved pension benefits. I confirm I am not a UK resident.
Signature	_____________________________________
Type your full name	Date

At this time we are only able to process this form with an original signature
PLEASE REVIEW CAREFULLY
PRINT AND SIGN THIS FORM AND FAX TO (813) 258-5902.