PWGSC-TPSGC 2223 - Supplementary Death Benefit Plan - Beneficiary Information

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Protected "B" when completed

Supplementary Death Benefit Plan - Beneficiary Information

Privacy Notice

Provision of the personal information, including the social insurance number (SIN), is required pursuant to the Department of Public Works and Government Services Act, para. 7(1)(d) and s. 13 and will be used for the purpose of administrating supplementary death benefits and CRA/RQ reporting and administrating the Public Service Superannuation Act (PSSA). Refusal to provide the personal information or the provision of incorrect information may result in loss of benefits and/or delays in processing, incorrect pension estimates, benefits, or statements. Personal information is protected, and only used and disclosed in accordance with the Privacy Act and as described in Personal Information Bank PWGSC PCU  702 – Federal Pension Administration. Under the Act, individuals have a right of access to their personal information and request correction, if erroneous or incomplete.

This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.

Plan Member's Personal Information

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Beneficiary Information

This is to certify that on the date of designation I was residing at the address below.


For Office Use Only

PWGSC-TPSGC 2223 (11/2014)