PWGSC-TPSGC 2483 - Statutory Declaration

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Protected "B" when completed

Statutory Declaration

In the matter of Provision of Pension Benefits Information Under the Pension Benefits Division Act

Provision of the information requested on this document is voluntary. This information is being collected for the purpose of documenting a request for division of pension benefits information under the Pension Benefits Division Act (PBDA). This information will be stored in Personal Information Bank number PWGSC PCE 702. It is protected from disclosure to unauthorized persons/agencies pursuant to the provisions of the Privacy Act. 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. Personal information that you provide about another individual may be accessible to that person under the Privacy Act. The information will be retained by the Department for two years following the last administrative action, and then destroyed.

Complete either Part 1 or Part 2, and complete Part 3

Part 1 - Married

Complete this section only if the member and the spouse are or were married.

, declare that I married

(Check the applicable box)

Part 2 - Not Married

Complete this section only if the member and the common-law partner were not married but have cohabited in a conjugal relationship for at least one year.

, declare that I started living with

(Check the applicable box)

Part 3 - During the period we were married or we lived together in a conjugal relationship, as noted above

(Check the applicable box)

(Indicate all breaks - Attach a separate sheet if necessary)

I make this Declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.

NOTE: Every person who knowingly makes a false or misleading representation in any application or other proceeding under the PBDA is guilty of an offence punishable on summary conviction.

PWGSC-TPSGC 2483 (09/2009)