Public Services and Procurement Canada
PDF Version (243Kb) Help on Alternative Formats
Protected "B" when completed
Provision of the information requested on this form is required in accordance with the Public Service Superannuation Act. The personal information collected is for designating the beneficiary. Refusal to supply the personal information on this form may result in not designating or changing the beneficiary. The information will be maintained in the Personal Information Bank Number PWGSC PCE 705, and it will be protected, used and disclosed in accordance with Privacy Act. Under the Act, you have the right to request access and correct your personal information, if erroneous or incomplete. The information 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 use dark ink and capital letters.
I hereby appoint the following beneficiary and revoke any previous designation.
NOTE: You must be a participant in the Supplementary Death Benefit (SDB) plan to complete this form; otherwise, the form will be invalid. You may cancel or change your beneficiary at any time while a participant, whether employed or retired.
Upon your death, your named beneficiary may become entitled to certain lump sum benefits which are payable under Part I of the Public Service Superannuation Act. A naming takes effect the date this form is completed; however, this form must be received by the Public Service Pension Centre prior to your death. Therefore, it is recommended that the completed form be forwarded by express mail to the address indicated below.
Important - You may only have one designated beneficiary at a time.
You may designate:
An ineligible or ambiguous designation will render this form invalid.
Completion of the Form
It is important that this form be received at the address indicated below as soon as possible.
Public Works and Government Services Canada
Public Service Pension Centre - Mail Service
150 Dion Blvd
PO Box 8000
Matane QC G4W 4T6
It is recommended that you forward this form by express mail.
PWGSC-TPSGC 2196 (09/2009)