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.

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)

do solemnly declare:

(Relation to deceased)

(Name of deceased public servant)

(Complete Address)

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

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

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.

(City, Town or Village)
day of

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)