Public Services and Procurement Canada
PDF Version (270Kb) Help on Alternative Formats
Protected "B" when completed
Provision of the information requested on this document is required by law in accordance with the Pension Benefits Division Act (PBDA) for the purpose of an application for division of a Public Service Superannuation Act (PSSA). 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 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 last administrative action, and then will be destroyed.
This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.
Current or former spouse/common-law partner of plan member
I hereby apply for the division of the pension benefits accrued to the plan member named herein under the Public Service Superannuation Act in accordance with the Pension Benefits Division Act.
The completed application and supporting documents are to be returned to:
Public Works and Government Services Canada
Public Service Pension Centre - Mail Facility
150 Dion Blvd
PO Box 8000
Matane QC G4W 4T6
NOTE: Every person who knowingly makes a false or misleading representation in any application or other proceeding under the Pension Benefits Division Act is guilty of an offence punishable on summary conviction.
PWGSC-TPSGC 2486 (09/2009)