PWGSC-TPSGC 1422—Deductions From Annuity or Annual Allowance

PWGSC-TPSGC 1422—Deductions From Annuity or Annual Allowance (PDF, 1.4MB)

Protected "B" when completed

Deductions From Annuity or Annual Allowance

Privacy notice

Provision of the personal information is required pursuant to the Department of Public Works and Government Services Act, para. 7(1)(d) and s.13 and will be used for the purpose of administrating the Public Service Superannuation Act (PSSA). Refusal to provide the personal information, or the provision of incorrect information may result in loss of benefits and/or delays in processing, incorrect pension estimates, benefits, or statements. Personal information is protected, and only used and disclosed in accordance with the Privacy Act and as described in Personal Information Bank (PWGSC PCU 702)—Federal Pension Administration. Under the Act, individuals have a right of access to their personal information and request correction, if erroneous or incomplete.

This form must be completed electronically or in dark ink using capital letters.

Instructions

  1. This form helps the Government of Canada Pension Centre (Pension Centre) to meet your needs as you end your employment and start receiving your monthly pension.

    Complete the form and return it to us to show which deductions to take from your pension.

    The completed form must be sent to the Pension Centre. Retain a copy for your records.

  2. Public Service Health Care Plan (PSHCP) Coverage—If you are already enrolled in the PSHCP and you wish to continue coverage after retirement, you must authorize that the necessary monthly premiums be deducted from your annuity. If these deductions are not authorized, your coverage will be cancelled.

    To be sure we understand your intention to either continue, amend, commence or cancel your coverage, please indicate your choice of coverage in the Deductions to be Taken section (see #1):

    • To continue means there are no amendments to be made to your coverage.

    • To amend your coverage, you must also complete and attach a PSHCP Pensioner Application form (TBS-006492).

    • To commence coverage if you are not a member of the PSHCP at the time your employment ends, you must apply for coverage by completing the TBS-006492 form and attaching it to this form.

    • To cancel coverage, you must also attach a letter stating that you wish to cancel your PSHCP coverage.

    Note: Certain Agencies and Public Service Corporations do not participate in the regular public service insurance programs. Former employees of those Agencies or Corporations cannot participate in the PSHCP as pensioners. If you are a member who is currently employed by an organization that does not participate in the PSHCP, please contact your employer for information concerning your eligibility to participate in a health care plan for retirees.

    PSHCP information and the monthly rates are available at: Canada.ca/pension-benefits.

  3. Government of Canada Workplace Charitable Campaign—Complete this block only if you currently have such a deduction. This deduction will cease at the end of the current calendar year if you do not complete a new pledge form for the new campaign year.

Plan Member's Personal Information

Preferred Language

Deductions to be Taken

Carefully read the Instructions section before completing the rest of this form.

This form must be completed to authorize deductions from your annuity.

To request that no deductions be taken from your annuity, go directly to the Signature of Plan Member section.

1. Public Service Health Care Plan (PSHCP) (see instruction 2)

Public Service Health Care Plan Choose a coverage
$

2. Government of Canada Workplace Charitable Campaign (see instruction 3)

$

3. Other Deductions

$

Signature of Plan Member

Please select one of the following options:

Signature:

For Office Use Only

PWGSC-TPSGC 1422 (01/2020)

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