PWGSC-TPSGC 2467 - Statutory Declaration

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Protected "B" when completed

Public Service Superannuation Act

Subsections 25 (4), 25 (4.1) and 25 (10) - Claimant's 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:

make this declaration for the purpose of establishing entitlement to survivor benefits payable in respect of the late

And Do Solemnly Swear That:

1. I commenced living with the plan member on


plan member continuously from the date indicated in Statement 1 to the date of the plan member's death

3. I did not live with the plan member during the following periods for the following reasons:


I did not live with the plan member during the following periods for the following reasons


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):

I lived with the plan member at the following addresses
I lived with the plan member at the following addresses

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)


  1. Examples of the types of details required for Statement 5 concern how and to what extent you 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). Explain how you each represented your relationship to family, friends, colleagues, and to others in the community. Please address the following items and any additional information that you consider relevant to your claim:
    1. The daily personal relationship with the plan member and care of each other;
    2. Joint participation in neighbourhood or community activities with the plan member and with each other's families and how those families behaved toward you;
    3. The attitude and conduct of the community towards you both as a couple;
    4. The financial arrangements between you and the plan member with respect to household expenses and ownership of property;
    5. Your attitude and conduct concerning your responsibility for children in your 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 (08/2010)