PWGSC-TPSGC 2069 - Pensionable Employment Questionnaire

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Protected "B" when completed

Pensionable Employment Questionnaire

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 electing to count under the PSSA a period of prior pensionable service with an outside employer. 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 the 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 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

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

Under the Public Service Superannuation Act, an employee may elect to count as pensionable service any qualifying period of employment with your organization which could have been counted upon becoming a member of your pension plan.

If pension records are not held in your office, forward this form to your pension plan administrator.

1. Release Authorization of the Employee

Period of Employment

I hereby authorize for release to the Public Service Pension Centre of Public Works and Government Services Canada, any information requested by this form regarding the time, duration and pensionable status of my former employment with your organization. I also authorize the release of information held by the pension plan administrator.

2. Particulars of Employment

1. Was this person subject to your pension fund or plan during his employment?

1. Was this person subject to your pension fund or plan during his employment?

If no, go to Section 5.

2. (a) The plan was:

2. (a) The plan was:

2. (b) In addition, please advise if your pension plan is registered under the Canadian Income Tax Act.

2. (b) In addition, please advise if your pension plan is registered under the Canadian Income Tax Act.

If yes, please indicate the registration date and number.

3. State the official title of your pension plan

4. Insert the exact dates of employment and pensionable service credit or benefit purposes under your pension plan in effect at the date this employee terminated his employment. Include any qualifying periods purchased or automatically credited (i.e. without cost to the employee) on becoming a member of your pension plan.

3. Particulars of Pension Benefits on Separation

A. Upon termination of employment, what type of benefit was the employee paid under your pension plan?

If you check (a), (b) or (c), please complete section "C" and "D" below.


Underwritten by Government Annuities Contract Branch

If any portion of the benefit remains to the employee's credit, please complete section B below.

B. Was the employee entitled to more than one type of benefit?

Indicate the period of service related to each benefit.

Subject to Lock-in Line 1
Subject to Lock-in
Transferable Line 1
Transferable Line 1

Period of Service Line 1

Subject to Lock-in Line 2
Subject to Lock-in
Transferable Line 2
Transferable Line 2

Period of Service Line 2

Subject to Lock-in Line 3
Subject to Lock-in
Transferable Line 3
Transferable Line 3

Period of Service Line 3

C. If the benefit was a type described in 3A(a), (b) or (c), was it transferred to:

Registered Pension Plan (RPP)
$

D. State the pensionable earnings and pension adjustment amounts for post 1989 service.

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

4. Plan Information

Please note that this section requests general information about your pension plan. It does not specifically relate to the circumstances of this former employee, except as to the provisions of the plan in effect at the time his participation under your plan ceased.

When the employee ceased to be a participant, did the pension plan in effect provide for an annuity type benefit that:

is provided in whole or in part as a result of contributions from the employer?
is related in amount to the period of service countable by the person to whom it is payable?
is payable in installments during the lifetime of the recipient and thereafter if the pension plan so provides?

5. Certification

The information provided in this questionnaire is certified to be correct

For Office Use Only

PWGSC-TPSGC 2069 (09/2009)