Public Services and Procurement Canada
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Protected "B" when completed
Provision of the information requested on this document is voluntary. This information is being collected for the purpose of documenting a request for pension benefits division information with respect to a Public Service Superannuation Act (PSSA) pension in accordance with the Pension Benefits Division Act (PBDA). 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 this Act, you have the right to request access to your personal information and to request corrections should you 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 by the department for two years following the last administrative action, and then will be destroyed.
Current or Most Recent Public Service Employer
I hereby request confirmation as to whether the person named in the attached document is the designated beneficiary in respect of the plan member's Supplementary Death Benefit under the PSSA. In support of this request, I have attached a certified true copy of a Court Order or written Agreement stating that I am to be named the beneficiary, or that I am entitled to this confirmation.
I hereby request pension benefits division information, in respect of the plan member named in Section (C) of this request, in accordance with the PBDA. I understand that a notation reflecting that such a request has been made will be placed on the plan member's personal records once the information is sent to me.
Note: Every person who knowingly makes a false or misleading representation in any application or other proceeding under the PBDA is guilty of an offence punishable on summary conviction.
PWGSC-TPSGC 2488 (09/2009)