Public Services and Procurement Canada
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Protected "B" when completed
This information is being collected in accordance with the Public Service Superannuation Act (PSSA) for the purpose of calculating pension contributions and is important to making a decision directly affecting the plan member. 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.
The compensation advisor/employer representative must complete and forward this form to the Public Service Pension Centre (Pension Centre) before the processing of the applicable pay activities. The form is to be completed when a plan member:
Once the form is received at the Pension Centre, the plan member will be informed of the deficiencies owing for his/her periods of Rehabilitation Leave or Educational LWOP (with allowance), as well as his/her payment options. In the case of a dual employment situation (same pay office, same department),
the Pension Centre will ensure that the recovery of deficiencies for the period of LWOP (excluding periods of dual employment)
is deferred until the plan member returns to work following his/her original LWOP.
Once completed, send the original form to:
Public Service Pension Centre -
150 Dion Blvd
PO Box 8000
Matane QC G4W 4T6
You may wish to retain a copy of the completed form for your records.
Indicate the days that were taken off for Educational LWOP during the period of service indicated in Part 1. The schedule of days off (ie off every Friday) can be provided, however, any changes in the schedule during the period of service must also be reported.
PWGSC-TPSGC 140 (05/2011)