Public Services and Procurement Canada
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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 pension diversion. This personal 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 the Act, you have the right to request access to your personal information and to request corrections should you believe the information contains errors or omissions. Personal information that you provide 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.
Most recent known and most recent known year at this address
Most recent place of employment in the Public Service and most recent year at that place (if known)
If yes, please indicate name and address.
If yes, please indicate full name, and address, and their legal relationship.
The original or certified true copy of the financial support order under which this application is made must be attached.
If the name on the financial support order is not the same as the name of the applicant (identified on the previous page), then you must provide either:
If the name on the financial support order is the same as the name of the applicant (identified on the previous page) and this person is a child then you must provide:
I hereby request the Minister of Public Works and Government Services Canada to divert from the recipient's net pension benefit an amount calculated in accordance with the provisions of the "Garnishment, Attachment and Pension Diversion Act" and Regulations.
Signature of Applicant or Representative:
Departmental General Counsel
Public Works and Government Services Canada
Phase III, 1C2, Place du Portage
Gatineau QC K1A 0S5
PWGSC-TPSGC 2460 (09/2009)