Form RST_XX07 Retired Ongoing Declaration Issued 1 Mar 2016
RAIL STAFF TRAVEL (part of the Rail Delivery Group)
DECLARATION BY REDUNDANT OR ILL-HEALTH RETIRED EMPLOYEE: ANNUAL PROOF
OF CONTINUED ELIGIBILITY ON THE GROUNDS OF UNEMPLOYMENT
Please read the Guidance Notes at www.raildeliverygroup.com – fill in your details, then either section (A) or (B).
RETIRED EMPLOYEE DETAILS
Title
Mr Ms Mrs
First name
Home address
Miss
NI No
Date of birth
Last name
Post code
Tel No
Email
Former Employer
Date ent’d service
Date left service
Reason: Ill health
Redundancy
(A) I ENCLOSE THE FOLLOWING DOCUMENTARY PROOF (TICK ONE BELOW TO USE OPTION A):
A statement from HMRC confirming that I have had no earned income for the last fiscal year and for any fiscal year
where I have not previously provided evidence of unemployment.
A statement from DWP confirming that I am currently unemployed and have been continuously unemployed in the
last 12 months and during any period where I have not previously provided evidence of unemployment.
A statement from my Doctor confirming that in his/her opinion I am unable to work owing to ill health and that this
has been the case for the last 12 months and during any period where I have not previously provided evidence of
unemployment.
(Note: if the Doctor confirms that owing to your condition you will never be able to work again, you won’t need to
provide annual proof in the future. Continued entitlement then may depend on the willingness of an employer to pay the
requisite fees)
(B) STATUTORY DECLARATION BY THE RETIRED/REDUNDANT EMPLOYEE (TICK TO USE OPTION B)
I have attempted to obtain the documentary proof described in (A) without success and have therefore
instead made the following Statutory Declaration before a Commissioner for Oaths:
I, the retired/redundant employee named above, declare that I continue to be eligible for retired travel
facilities owing to continued unemployment. I have not worked at all since I left the rail employer named
above. I make this Declaration conscientiously believing the same to be true by virtue of the Statutory
Declarations Act 1835, and understand that there could be serious consequences should the facts herein
be less than wholly accurate.
CONFIRMATION TO BE COMPLETED BY A COMMISSIONER FOR OATHS
I confirm that the above-named has declared that he/she has been continuously unemployed since leaving
the service of the rail employer named above.
Company/firm name
Signature of authorised official
Name (printed) of authorised official
Date
Company/firm stamp
By signing this form, I also confirm that if my circumstances change and I commence work, I will
immediately surrender any rail staff travel cards or passes held by me and, if appropriate, family members.
Signature of employee
Date of Declaration
Once completed (save as “YourLastname_1607_YourNINumber”) submit via your normal travel contact point/email to [email protected].