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) when an employee has missed a service buyback payment called "default". The 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, 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 that you provide about another in dividual may be accessible to that person under the Privacy Act. The records will be retained by the Department for two years following last administrative action, and then destroyed.
This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.
3 - The payments of the above-named plan member are in default - Period of Default
4 - Monthly Deductions Taken
5 - Lump sum payments received
6 - Certification
I hereby certify that the above information is an accurate transcription of pay office records. The deductions will continue at the indicated monthly rate, unless further notification is received from the Public Service Pension Centre.
PWGSC-TPSGC 1871 (03/2010)