PWGSC-TPSGC 2484 - Statutory Declaration

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Protected "B" when completed

Statutory Declaration

In the matter of an application for Division of Pension Benefits under the Pension Benefits Division Act

members PRI number Member's PRI or Pension No.

Provision of the information requested on this document is voluntary. This information is being collected for the purpose of documenting an application for division of pension benefits under the Pension Benefits Division Act (PBDA). 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 provisions of the Privacy Act. Under this 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 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.

Complete either Section 1 or 2, and Section 3

Section 1 - Married

Complete this section only if the plan member and the spouse were married and are now either separated or divorced.

I, (Complete Name of Declarant)

, declare that I married

Complete Name of Spouse or Former Spouse (Complete Name of Spouse or Former Spouse)

Married on (Y-M-D)

(Check the applicable box)

If divorced:

If divorced We have lived separate and apart since: (Y-M-D)

We were divorced on (Y-M-D)

If separated:

We have lived separate and apart since: (Y-M-D)

Section 2 - Not Married

Complete this section only if the plan member and the common-law partner were not married, but have cohabited in a conjugal relationship for at least one year and are now living separate and apart.

Not Married I, (Complete Name of Declarant)

, declare that I started living with

Not Married - Complete Name of Common-law Partner or Former Partner (Complete Name of Common-law Partner or Former Partner)

in a conjugal relationship on
(Y-M-D)

We have lived separate and apart since

Separated date (Y-M-D)

Section 3 - During the period we were married or we lived together in a conjugal relationship, as noted above

(Check the applicable box)

There were no periods when we lived separate and apart due to a breakdown in our relationship.

We lived separate and apart due to a breakdown in our relationship on the following dates

(Indicate all breaks - Attach a separate sheet if necessary)

From (Y-M-D)

To (Y-M-D)

Break 2 From (Y-M-D)

Break 2 To (Y-M-D)

I make this Declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.

Declared before me at (City, town or Village)

on (Y-M-D)

in the province of

Signature of Declarant

Expiry Date (if applicable) (Y-M-D)

Indicate whether lawyer, commissioner of oaths, notary public (Stamp, seal, expiry date if applicable)

Stamp

NOTE: Every person who knowingly makes a false or misleading representation in any application or other proceeding under the PBDA is guilty of an offence punishable on summary conviction.

PWGSC-TPSGC 2484 (09/2009)