PWGSC-TPSGC 2010 - Statutory Declaration

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Statutory declaration

Provision of the information requested on this document is required by law in accordance with Section 25 of the Public Service Superannuation Act to allow for the payment of a child's allowance upon the death of a contributor. This information is stored in Personal Information Bank number PWGSC PCE 702 and is protected from disclosure to unauthorized persons/agencies pursuant to the provisions of the Privacy Act. Under the Act, you have the right to request access to your personal information, held by a federal government institution, 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.

Pension number

This form is required for purposes of Section 25 of the Public Service Superannuation Act and should be completed by the survivor or other person(s) having custody and control of dependant children.

In the matter of the Public Service Superannuation Act

(Name in full)

(Complete address)

in the county of

Public Service Superannuation Act province of

do solemnly declare:

That I am the

(Relation to deceased)

of the late

(Name of deceased public servant)

do solemnly declareof

(Complete address)

do solemnly declarein the County of

do solemnly declare Province of

That the dependant children (include stepchildren and adopted children) now alive of the said late plan member, and their birth dates are as follows:

Live dependant child 1Name

Live dependant child 1Date of birth (Y-M-D)

Live dependant child 2Name

Live dependant child 2Date of birth (Y-M-D)

Live dependant child 3 (Y-M-D)Name

Live dependant child 3Date of birth (Y-M-D)

Live dependant child 4Name

Live dependant child 4Date of birth (Y-M-D)

That I have custody and control of all the above-named dependant children, OR the following dependant children:

Custody of dependant child 1Name

Custody of dependant child 1Date of birth (Y-M-D)

Custody of dependant child 2Name

Custody of dependant child 2Date of birth (Y-M-D)

Custody of dependant child 3Name

Custody of dependant child 3Date of birth (Y-M-D)

Custody of dependant child 4Name

Custody of dependant child 4Date of birth (Y-M-D)

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

Declared before me at

(City, Town or Village)

Declared before me atIn the province of

on this

day of

Month

Year

(Indicate whether Justice of the Peace, Commissioner for oaths, Notary, or other authorized person.)

Signature of declarant

Official title (if applicable)

Send completed declarations to:

Public Works and Government Services Canada-Public Service Pension Centre-Mail Facility
150 Dion Blvd, PO Box 8000
Matane QC G4W 4T6

PWGSC-TPSGC 2010 (03/2012)