PWGSC-TPSGC 2488 - Request for Pension Benefits Division Information with Respect to a Public Service Superannuation Act Pension in Accordance with the Pension Benefits Division Act

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Protected "B" when completed

members PRI number Member's PRI or Pension No.

Request for Pension Benefits Division Information with Respect to a Public Service Superannuation Act Pension in Accordance with 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 pension benefits division information with respect to a Public Service Superannuation Act (PSSA) pension in accordance with 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 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.

A. Applicant

Surname

Given Names

I'm applying as the

plan member

current or former spouse/common-law partner of the plan member

personal representative of the

personal representative of the Plan Member

personal representative of theCurrent or former spouse/common-law partner of the plan member

B. Address to which pension benefits division information is to be sent

Address

C. Plan Member

Plan Member Surname

Plan Member Given Names

Plan Member Date of Birth (Y-M-D)

Plan Member Telephone No.

Current or Most Recent Public Service Employer

Department

Location

Human Resources Contact Person

Human Resources Contact Person Telephone No.

Human Resources Contact Person Member's PRI or Pension No.

Date of Retirement
(if applicable) (Y-M-D)

D. Confirmation of beneficiary status for supplementary death benefit (only if stipulated in an attached Court Order or written Agreement)

I hereby request confirmation as to whether the person named in the attached document is the designated beneficiary in respect of the plan member's Supplementary Death Benefit under the PSSA. In support of this request, I have attached a certified true copy of a Court Order or written Agreement stating that I am to be named the beneficiary, or that I am entitled to this confirmation.

Signature

Date (Y-M-D)

E. Supporting Documents

Supporting Documents

Copy of the court order or original or written Agreement providing for the division of the plan member's PSSA pension benefits

Original or certified true copy of other document (if applicable) that authorizes a personal representative to act on behalf of the plan member, or the current or former spouse/common-law partner

Statutory Declaration (PWGSC-TPSGC 2483) outlining period(s) of cohabitation and any breaks therein (if applicable)

F. Applicant's Signature

I hereby request pension benefits division information, in respect of the plan member named in Section (C) of this request, in accordance with the PBDA. I understand that a notation reflecting that such a request has been made will be placed on the plan member's personal records once the information is sent to me.

Applicant's Signature

Applicant's Date (Y-M-D)

Applicant's Telephone Number

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 2488 (09/2009)