PWGSC-TPSGC 2123 - Certification of Leave Without Pay

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Protected "B" when completed

Certification of Leave Without Pay

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.

Plan Member's Personal Information

Preferred Language
Preferred Language

Instructions:

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.

Section A - To identify the plan member's employing department during a specific period of elective service

Leave Without Pay (LWOP)

Section B - To identify the period of Leave of without pay (LWOP) which occurred during prior contributory service

Period(s) of pensionable LWOP

Section C - To identify the periods of service where the employee has previously opted not to count LWOP as pensionable service

Option not to count LWOP as pensionable service

Section C Reason Codes

  1. Maternity
  2. Personal
  3. Illness
  4. Education leave
  5. Parental leave
  6. The period of LWOP consists of CSC operational service (please specify in Section G if the leave was at single or double rate of contribution)
  7. Other (please specify in Section G)

Section D - To identify periods of non-pensionable service which occurred during prior contributory service and which will never be elective

Non-pensionable Service

Section D Reason Codes

  1. Unauthorized leave without pay
  2. Suspension
  3. Strike
  4. Sessional or seasonal layoff
  5. LWOP exceeding the 5-year limit permissible
  6. Other (please specify in Section G)

Section E - Completion of this section is not required if the return of contributions was paid prior to January 1, 1997

Pensionable earnings for post-1989 service for each calendar year

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.

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Section F

Was the ROC paid in cash?

Was the ROC paid in cash?

If no, was it transferred to

If no, was it transferred to

What portion of the ROC applies to service which occurred after December 31, 1989?

$

Section G - Provide additional information associated with the periods being certified and/or identified in sections B, C and D

Section H

I certify that the above data accurately reflects the information contained in the appropriate official records.

For Office Use Only

  • Original: Public Service Pension Centre - Mail Facility
  • Copies: 1 - Personnel Office

PWGSC-TPSGC 2123 (09/2009)