PWGSC-TPSGC 2265 - Disability Benefit from CPP or QPP
Protected "B" when completed
Provision of 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 confirming if the plan member is entitled to a Canada Pension Plan (CPP) or Quebec Pension Plan (QPP) disability benefit 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.
You can fill out this form electronically and print it. Or, you can print a blank form and fill it out in dark ink using capital letters.
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