PWGSC-TPSGC 2484 - Statutory Declaration

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Protected "B" when completed

Statutory Declaration

In the matter of an application for Division of Pension Benefits 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 an application for division of pension benefits under the Pension Benefits Division Act (PBDA). This personal information will be stored in Personal Information Bank Number PWGSC PCE 702 and will be protected, used and disclosed in accordance with the provisions of the Privacy Act. Under this act, you have the right to request access to your personal information and to request corrections should you believe the information contains errors or omissions. Personal information provided about another individual may be accessible to that person under the Privacy Act. The records will be retained by the department for two years following the last administrative action, and then will be destroyed.

Complete either Section 1 or 2, and Section 3

Section 1 - Married

Complete this section only if the plan member and the spouse were married and are now either separated or divorced.

, declare that I married

(Check the applicable box)

Section 2 - Not Married

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

, declare that I started living with

Section 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 2484 (09/2009)