PWGSC-TPSGC 2467-1 - Statutory Declaration

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Protected "B" when completed

Public Service Superannuation Act

Subsections 25 (4), 25 (4.1) and 25 (10) - Supporting Statement

IN THE MATTER OF Survivor Benefits under the Public Service Superannuation Act

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.

To Witness:



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:


Line 2
Line 3

I MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true and knowing that it has the same effect as if made under oath.


  1. For the purposes of Statement 5, please include details concerning your knowledge and to what extent the claimant and the plan member shared finances, shared ownership of property and household items, shared domestic responsibilities, participated jointly in social or recreational activities and shared responsibility for children (if applicable), and explain how they each represented their relationship to family, friends, colleagues and to others in the community. Please address the following items or any other relevant details.
    1. the daily personal relationship of the claimant and the plan member and their care of each other;
    2. their joint participation in neighbourhood or community activities and with each other's families and how those families behaved toward each of them;
    3. the attitude and conduct of the community towards them both as a couple;
    4. the financial arrangements between them with respect to household expenses and ownership of property; and
    5. their attitude and conduct concerning the responsibility for children in their care.
  2. Other federal superannuation acts:
    • Canadian Forces Superannuation Act
    • Royal Canadian Mounted Police Superannuation Act
    • Members of Parliament Retiring Allowances Act
    • Diplomatic Service (Special) Superannuation Act
    • Lieutenant Governors Superannuation Act
    • Governor General's Act
    • Judges Act
  3. If there is not enough space on the declaration form to answer a question fully, attach additional pages and in the response to that question on the form, indicate how many pages are attached. Each attached page must be initialed by you and by the person before whom the statement is being sworn.

PWGSC-TPSGC 2467-1 (08/2010)