PWGSC-TPSGC 2223 - Supplementary Death Benefit Plan - Beneficiary Information

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Supplementary Death Benefit Plan - Beneficiary Information

Privacy Notice

Provision of the personal information, including the social insurance number (SIN), is required pursuant to the Department of Public Works and Government Services Act, para. 7(1)(d) and s. 13 and will be used for the purpose of administrating supplementary death benefits and CRA/RQ reporting and administrating the Public Service Superannuation Act (PSSA). Refusal to provide the personal information or the provision of incorrect information may result in loss of benefits and/or delays in processing, incorrect pension estimates, benefits, or statements. Personal information is protected, and only used and disclosed in accordance with the Privacy Act and as described in Personal Information Bank PWGSC PCU 702 – Federal Pension Administration. Under the Act, individuals have a right of access to their personal information and request correction, if erroneous or incomplete.

This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.

Plan Member's Personal Information

Surname

Plan Member's Personal Information PRI

Given Names

Pension No.

Preferred Telephone No.

Date of Birth (YYYYMMDD)

Preferred Language

English French

Home address

Apartment No.

City

Province

Postal Code

Country

Email Address (optional)

Beneficiary Information

Name of Beneficiary

Social Insurance No.

Date of Birth (Y-M-D)

Current Mailing Address

Tel. No.

Date of Designation (Y-M-D)

This is to certify that on the date of designation I was residing at the address below.

Address

To the best of my knowledge, I am the person designated as the beneficiary of the late

Signed at

this (Day)

day of (Month)

(Year)

Signature of Beneficiary

Signature of Witness

For Office Use Only

Form No.

Case No.

PRI

For Office Use Only Pension No.

PWGSC-TPSGC 2223 (11/2014)