Public Services and Procurement Canada
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Protected "B" when completed
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.
make this declaration for the purpose of establishing entitlement to survivor benefits payable in respect of the late
1. I commenced living with the plan member on
3. I did not live with the plan member during the following periods for the following reasons:
4. I lived with the plan member at the following addresses (listing the most recent address first):
5. The details of my relationship with the plan member during the period of our cohabitation are as follows (see following page for instructions):
6. The following steps were taken to formalize our relationship in order to protect our status as a couple (e.g. cohabitation agreement, power of attorney, authorization to make medical decisions on behalf of your partner, etc.).
7. I have submitted an application for survivor benefits in respect of this plan member under the following other federal superannuation acts (see instructions below for list of acts).:
I MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true and knowing that it has the same effect as if made under oath.
Signature of person authorized to take a Statutory Declaration. (Indicate whether a Justice of the Peace, Notary, Lawyer, Commissioner of Oaths (expiry date must be indicated), etc. and use stamp or seal)
PWGSC-TPSGC 2467 (08/2010)