PWGSC-TPSGC 2223 - Supplementary Death Benefit Plan - Beneficiary Information

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Protected "B" when completed

Supplementary Death Benefit Plan - Beneficiary Information

Provision of the information requested on this form may be used for the purpose of establishing entitlement to benefits under the Public Service Superannuation Act (PSSA). 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, 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 individual may be accessible to that person under the Privacy Act. The information will be retained by the Department for two years following the last administration change and then 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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Beneficiary Information

This is to certify that on the date of designation I was residing at the address below.

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For Office Use Only

PWGSC-TPSGC 2223 (09/2009)