Public Services and Procurement Canada
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This information is being collected for the purpose of documenting another individual's claim for survivor benefits under the Public Service Superannuation Act and will be stored in Personal Information Bank No. PWGSC PCE 702. Provision of the information requested on this document is voluntary. You may, without prejudice to you, decline to respond. This information is protected from disclosure to unauthorized persons/agencies pursuant to the provisions of the Privacy Act and will only be used for the purpose for which it was obtained or for a use consistent with that purpose. Under the Act, you have the right to request access to your personal information, held by a federal government institution, and to request corrections should you believe the information contains errors or omissions. You should be aware that personal information that you provide about another individual may be accessible to that person under the Privacy Act. Further, any information that you provide may be accessible to a person whose entitlement to benefits is affected by the outcome of the applicant's claim. In the event that the applicant makes a similar claim for survivor benefits under another federal public sector pension plan (see number 2 in the instructions) in respect of the same plan member, any information provided will be accessible to the federal institution administering that plan.
AND DO SOLEMNLY SWEAR THAT:
4. I am aware of the following breaks in the relationship of the claimant and the plan member during the period from the date indicated in Statement 3 to the date of the plan member's death for the following reasons:
I MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true and knowing that it has the same effect as if made under oath.
PWGSC-TPSGC 2467-1 (08/2010)