Public Services and Procurement Canada
PDF Version (686Kb) Help on Alternative Formats
Protected "B" when completed
Provision of the information requested on this document is voluntary. This information is being collected in accordance with the Public Service Superannuation Act (PSSA) for the purpose of electing to count under the PSSA a period of prior pensionable service with an outside employer. This personal information will be stored in Personal Information Bank Number PWGSC PCE 702 and will be protected, used and disclosed in accordance with the Privacy Act. Under the act, employees have the right to request access to their personal information and to request corrections should they believe the information contains errors or omissions. Personal information provided about another individual may be accessible to that person under the Privacy Act. The records will be retained for two years following the last administrative action, and then will be destroyed.
This form must be completed electronically. If not possible, please use dark ink and capital letters.
Under the Public Service Superannuation Act, an employee may elect to count as pensionable service any qualifying period of employment with your organization which could have been counted upon becoming a member of your pension plan.
If pension records are not held in your office, forward this form to your pension plan administrator.
Period of Employment
I hereby authorize for release to the Public Service Pension Centre of Public Works and Government Services Canada, any information requested by this form regarding the time, duration and pensionable status of my former employment with your organization. I also authorize the release of information held by the pension plan administrator.
If no, go to Section 5.
If yes, please indicate the registration date and number.
If you check (a), (b) or (c), please complete section "C" and "D" below.
If any portion of the benefit remains to the employee's credit, please complete section B below.
Indicate the period of service related to each benefit.
Period of Service Line 1
Period of Service Line 2
Period of Service Line 3
Please note that this section requests general information about your pension plan. It does not specifically relate to the circumstances of this former employee, except as to the provisions of the plan in effect at the time his participation under your plan ceased.
When the employee ceased to be a participant, did the pension plan in effect provide for an annuity type benefit that:
The information provided in this questionnaire is certified to be correct
PWGSC-TPSGC 2069 (09/2009)