PWGSC-TPSGC 570 - Service Buyback Payment Transmittal for Plan Member on Leave Without Pay

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Service Buyback Payment Transmittal for Plan Member on Leave Without Pay

Provision of the information requested on this document is voluntary. The information is being collected in accordance with the Public Service Superannuation Act (PSSA) for the purpose of remitting payments in respect of a leave without pay period and/or a service buyback. This personal information will be stored in Personal Information Bank Number PWGSC PCU 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 complete it in dark ink using capital letters.

Plan Member's Personal Information

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Carefully read instructions before completing.

This form should be used by plan members during a leave without pay period to remit service buyback payments to the Public Service Pension Centre.

This form provides information necessary for accounting purposes.

Cheques must be made payable to the Receiver General for Canada and forwarded to:

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

 
$
$

This payment covers the following month(s):

For Office Use Only

PWGSC-TPSGC 570 (09/2009)