Public Services and Procurement Canada
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Protected "B" when completed
Provision of the information requested on this document is voluntary and is required to comply with the provisions of the Public Service Superannuation Act (PSSA). The personal information is collected for the purpose of reporting leave without pay which occurred during a period of prior elective pensionable service and is important to making a decision directly affecting the employee's pension. Non-completion of this form may result in incorrect pension estimates and statements. The information is maintained in Personal Information Bank Number PWGSC PCE 702 (Public Service Pensions Data Bank) and is protected from disclosure in accordance with the provisions of the Privacy Act. Under this Act, the employee has the right to request access and correction of his personal information, if erroneous or incomplete. The records are retained for two years following the last administrative action and then destroyed.
This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.
This form is to be completed by the employing department or agency to report periods of authorized or unauthorized leave without pay, strike and suspension which occurred during prior contributory service which the plan member has chosen to count as pensionable service under the terms of the PSSA. It is also required for all buybacks for prior contributory public service that occurred on and after January 1, 1990 for which a lump sum benefit, such as a return of contributions (ROC), was paid upon termination of employment, regardless if the plan member was on leave without pay, strike and suspension during that time. Upon completion, this form is to be forwarded to the Public Service Pension Centre.
Period(s) of pensionable LWOP
Option not to count LWOP as pensionable service
NOTE: Report pensionable earnings (excluding overtime salary and non-superannuable allowances) for each payroll calendar year beginning January 1, 1990, but only in correspondence with the above-mentioned periods of services under Section A.
Was the ROC paid in cash?
If no, was it transferred to
What portion of the ROC applies to service which occurred after December 31, 1989?
I certify that the above data accurately reflects the information contained in the appropriate official records.
PWGSC-TPSGC 2123 (09/2009)