PWGSC-TPSGC 570 - Payment Transmittal Form

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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 remitting service buyback payments while on leave without pay. 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, 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 by the department 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.

Plan Member's Personal Information

• Surname:
• Personal Record Identifier (PRI):
• Given names:
• Pension Number:
• Date of Birth (YYYYMMDD):
• Preferred language: English / French
• Preferred Telephone Number (123-456-7890):
• Home Address:
• Apartment Number:
• City:
• Province:
• Postal Code:
• Country:
• Email Address (optional):

FOR OFFICE USE ONLY

• Form Number: 570
• Case Number:

• Form Number: 570
• PRI:
• Pension Number:

Carefully read instructions before completing.

This form is used by the plan member for the purpose of remitting payments in respect of a period of leave without pay and/or a service buyback. This form provides information necessary for accounting purposes.

Send the completed form to the following address together with your payment:

Public Service Pension Centre - Mail Facility
150 Dion Blvd
PO Box 8000
Matane QC G4W 4T6

Cash payments such as personal cheques and money orders must be made payable to the Receiver General for Canada.

If sending a payment in respect of more than one service buyback, indicate the total of the monthly deduction amount for all service buybacks.

If your payment is made through a direct transfer of funds from a Registered Retirement Savings Plan (RRSP), complete and attach the Canada Revenue Agency form T2033 to this form (in lieu of a cheque or money order).

Note: In Part C of the form T2033 indicate "0288795" for the CRA registration number and "Public Service Superannuation Account" for the registered pension plan (RPP) name.

Residents of Ontario and Québec must add the provincial sales tax to the amount of Supplementary Death Benefit (SDB) contributions, 8% for Ontario and 9% for Québec .

Payment Information

The payment is for:

• Pension Contributions:
• Supplementary Death Benefit (SDB) Contributions:
• Service Buyback Payments:

• Monthly Deduction Amount:
• (required for service buyback only)
• Amount of Payment:
• This payment covers the following period: From (Y M D) To (Y M D)

PWGSC-TPSGC 570 (04/2011)