PWGSC-TPSGC 1422 - Deductions From Annuity or Annual Allowance

PDF Version (155Kb) Help on Alternative Formats

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. If not possible, please complete it in dark ink using capital letters.

Plan Member's Personal Information

Preferred Language
Preferred Language

Carefully read instructions before completing

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

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

Plan

1. Medical Service Plan of British Columbia

$

2. Medavie Blue Cross

$

3. Veterans Insurance

$

4. Canada Savings Bonds

$

5. Public Service Health Care Plan (PSHCP) (See instructions 2 and 3)

5. Public Service Health Care Plan (PSHCP)
$

6. Government of Canada Workplace Charitable Campaign (see instruction 4)

$

7. Other Deductions (please specify)

$

Signature of Plan Member

Please check one of the following boxes:

To be completed by the Government of Canada Pension Centre

Type of Entitlement

For Office Use Only

Deductions From Annuity or Annual Allowance - Instructions

  1. This form is required by the Department of Public Works and Government Services Canada to assist plan members who will terminate employment and receive a monthly pension benefit to maintain an orderly flow of legal assignment payments and to minimize the inconvenience which might be caused by a delay in these payments.
    • The completed form must be sent to the Government of Canada Pension Centre. Retain a copy for your records.
  2. Public Service Health Care Plan participation continues automatically unless you indicate in block 5 you intend to cancel and/or you request that no deductions are to be taken from your annuity. If you want to modify your participation, you must complete the application form TBS-006492 or request the changes in a letter. The application or letter must be attached to this form.
  3. If you are not a member of the Public Service Health Care Plan at the time of termination of employment and you would like this coverage, you must apply by completing form TBS-006492 and attaching it to this form.
    • The form can be obtained at: Your Public Service Pension and Benefits
    • 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 these programs as pensioners. If you are a member who is currently employed by an organization who does not participate in the Public Service Health Care Plan, please contact your employer for information concerning your eligibility to participate in a health care plan for Retirees.
  4. 4. Government of Canada Workplace Charitable Campaign (GCWCC). Complete only if you currently have a GCWCC deduction. Unless a new pledge form is completed for the new campaign year, this deduction will cease at the end of the current calendar year.

PWGSC-TPSGC 1422 (12/2009)