Public Services and Procurement Canada
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Protected "B" when completed
Provision of the information requested on this document is voluntary. This information is being collected in accordance with the Public Service Superannuation Act (PSSA) for the purpose of surrendering benefits under the Canadian Forces Superannuation Act (CFSA) or the Royal Canadian Mounted Police Superannuation Act (RCMPSA). This information will be stored in Personal Information Bank Number PWGSC PCE 702 and will be protected, used and disclosed in accordance with the Privacy Act. Under this act, employees have the right to request access to their personal information and to request corrections should they believe the information contains errors or omissions. Personal information provided about another individual may be accessible to that person under the Privacy Act. The records will be retained by the department for two years following the last administrative action, and then will be destroyed.
This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.
Payable under the Canadian Forces Superannuation Act (CFSA) or the Royal Canadian Mounted Police Superannuation Act (RCMPSA).
NOTE: To be completed by recipients of monthly pensions or by persons who have not received or are not entitled to receive a return of CFSA or RCMPSA contributions.
NOTE: Pay Office (PO), Paylist (PL), and Department (Dept.) can be found on the upper left hand corner of your pay stub.
When completed, retain a copy and forward the original to:
Pension Services Directorate
Public Works and Government Services Canada
1451 Coldrey Avenue
Ottawa ON K1A 0S5
Attention: Specialized Services Division - Canadian Forces
Public Works and Government Services Canada – RCMP
Government of Canada Pension Centre – Mail Facility
150 Dion Boulevard
PO Box 8500
Matane QC G4W 0E2
NOTE TO CFSA/RCMPSA: Original to be forwarded to Public Service Pension Centre - Mail Facility by the CFSA/RCMPSA plan administrator
PWGSC-TPSGC 2092 (09/2009)