PWGSC-TPSGC 2010 – Guardianship and payment declaration for children under the age of 18

Protected B when completed

In the matter of the Public Service Superannuation Act (PSSA)

Pension number
Please enter a valid 9-digit number starting with zero.

I, (Full name)

of (Complete address)

do solemnly declare that:

I am the (Relation to deceased)

of the late (Name of deceased plan member)

I am the parent guardian

who has parental decision making responsibility of the following child or children with respect to benefits payable under the PSSA.

Children
Children	Full name	Date of birth (YYYYMMDD)	Social Insurance Number (SIN) (Enter 9 digits)^{footnote *}
Child

To the best of my knowledge, the child or children listed above are Supplementary Death Benefit (SDB) beneficiaries of the above noted deceased plan member. (Check if applicable.)

I hereby authorize and direct that any one-time, lump sum payment be made to myself in trust for the above noted child*. In consideration of a payment made in accordance with this Direction, I hereby agree to indemnify and hold the Minister and the Government of Canada harmless against any claims, liability, (etc.).

I certify that this declaration is true and complete, and that I will accept payment on the child’s behalf.

Signature

Date (YYYYMMDD)

This form must be notarized when the person who has parental decision making responsibility of the child or children is not the natural or adoptive parent:

Sworn (or affirmed) before me at

in the province of

this

day of

Full name, signature and title

Full name

Signature

Title

Indicate whether you are a Justice of the Peace, Commissioner of oaths, Notary, or other authorized person
(include stamp, seal or expiry date if applicable).

Stamp

Send this completed declaration to:

Public Works and Government Services Canada
Government of Canada Pension Centre
Mail Facility
150 Dion Blvd, PO Box 8000
Matane QC G4W 4T6

* Child allowance payments do not need to be paid in trust.

PWGSC-TPSGCPWGSC-TPSGC 2010E (2024-04-25)

PWGSC-TPSGC 2010 – Guardianship and payment declaration for children under the age of 18

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In the matter of the Public Service Superannuation Act (PSSA)

Child