Public Services and Procurement Canada
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Protected "B" when completed
Provision of the information requested on this form may be used for the purpose of providing pertinent information to issue the Supplementary Death Benefit payment under the Public Service Superannuation Act (PSSA). This personal information will be 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. The information will be retained by the Department for two years following the last administrative change and then destroyed.
This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.
1. Period of Leave Without Pay
PWGSC-TPSGC 2014 (05/2011)