Public Services and Procurement Canada
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Provision of the information requested on this document is voluntary (except Section B) and is being collected in accordance with the Public Service Superannuation Act (PSSA) for plan enrolment, service buyback and pension benefit purposes. 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, employees have the right to request access to personal information about themselves and may request corrections should they 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 will then be destroyed.
This form must be completed in dark ink using capital letters or completed electronically.
The completion of this section is mandatory. All the information requested is being collected under the authority of the Treasury Board for the administration of the Public Service Superannuation Act and will be protected under the provisions of the Privacy Actin Personal Information Bank Number PWGSC PCE 702 . Access to this information is controlled by the Director General of the Public Service Pension Centre.
Carefully read instructions before completing.
The Orientation Information kit and the Notification of Plan Membership should be read prior to the completion of this form.
Check the boxes to acknowledge receipt of the Notification of Plan Membership and indicate that you have read and are aware of the information supplied.
Sign and date the form.
Your Public Service Pension and Benefits
Indicate if you do or do not have service in each of the three categories listed. If you answer "yes" to any of the three questions, indicate the name of the organization(s), the start and end dates of the applicable periods, whether or not you participated in a pension plan, and the type of benefit(s) received upon termination. Providing this information will help identify opportunities to increase your pensionable service.
If you have service with the Canadian Forces or RCMP, provide your Regimental No./Rank and your CF/RCMP Pension No.
In order to ensure pensionable service is calculated correctly, the pension administrator requires the above information.
You may only accrue up to a maximum of 35 years of pensionable service under the Public Service pension plan . This 35-year maximum includes service that is pensionable under certain other federal government pension plans for which you retain a benefit entitlement, such as the Canadian Forces pension plan or the Royal Canadian Mounted Police pension plan.
Attach a separate sheet if space is insufficient
For the purpose of determining a plan member's eligible dependants, provide the full name of your spouse or common-law partner (if applicable) and the full name and date of birth for any children under the age of 25 (if applicable), to assist in the payment of potential benefits in the event of your death.
Note: You are required to submit proof of your marital status and proof of age for your children to the pension plan administrator (photocopies are accepted).
Identify the following if applicable:
Spouse or common-law partner
Child Under Age 25
Please complete all sections of this form.
Both the Personal Record Identifier (PRI) and Pension Number can be found on your Notification of Plan Membership.
This form must be mailed to:
Public Service Pension Centre
150 Dion Blvd
P.O. Box 8000
Matane QC G4W 4T6
PWGSC-TPSGC 571 (12/2009)