Public Services and Procurement Canada
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Protected "B" when completed
Provision of the personal information is required pursuant to the
Department of Public Works and Government Services Act, para. 7(1)(d)
and s.13 and will be used for the purpose of administrating the Public
Service Superannuation Act (PSSA). Refusal to provide the personal
information, or the provision of incorrect information may result in loss
of benefits and/or delays in processing, incorrect pension estimates,
benefits, or statements. Personal information is protected, and only used
and disclosed in accordance with the Privacy Act and as described in
Personal Information Bank PWGSC PCU 702 – Federal Pension
Administration. Under the Act, individuals have a right of access to their personal information and request correction, if erroneous or incomplete
This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.
This form must be completed to authorize deductions from your pension.
To request that no deductions be taken from your annuity, go directly to the Signature of Plan Member.
1. Medical Service Plan of British Columbia
2. Medavie Blue Cross
3. Veterans Insurance
4. Canada Savings Bonds
5. Public Service Health Care Plan (PSHCP) (See instructions 2 and 3)
6. Government of Canada Workplace Charitable Campaign (see instruction 4)
7. Other Deductions (please specify)
PWGSC-TPSGC 1422 (12/2009)