ARCHIVED ANNEX A

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NOTIFICATION OF DEATH IN SERVICE

The Public Works and Government Services Canada (PWGSC)- Travaux publics et Services gouvernementaux Canada (TPSGC) / PWGSC-TPSGC 2014 is completed when a plan member covered under the public service pension plan dies in service. To ensure that plan members' survivors or their legal representatives receive timely pension benefits information and that Supplementary Death Benefit (SDB) payments are paid quickly, the PWGSC-TPSGC 2014 form should be faxed to the Public Service Pension Centre (Pension Centre or PSPC) as soon as the employer representative is advised of the death of a plan member.

This form is sent to the Pension Centre to advise of a death in service and to indicate the employee's authorized salary rate and any outstanding SDB deficiencies to be recovered from the SDB payment, if applicable.

On receipt of the PWGSC-TPSGC 2014, the Pension Centre will determine eligibility to a SDB payment and will contact the SDB beneficiary directly to advise of the procedures for claiming the benefit. In addition, the Pension Centre will contact the plan members' survivors or their legal representatives to advise of any pension benefits that are payable.

The PWGSC-TPSGC 2014 form should be distributed as follows:

• Original -- Pension Centre
• Copy -- Personnel Office

Crown corporations, agencies and territorial governments not serviced by the Regional Pay System (RPS) must ensure that all portions of the employer representative and Pay Office (PO) sections are completed by the responsible parties.

PART A: TO BE COMPLETED BY THE EMPLOYER REPRESENTATIVE OR DESIGNATED PERSON.

Instructions to complete the information on salary / allowance

FIELD	INSTRUCTIONS
DATE OF DEATH	Insert the employee's date of death (YYYYMMDD).
PO	Insert, if applicable, the appropriate two-digit numeric code for the PO.
DEPT.	Insert the employing department code.
Paylist (PL)	Insert, if applicable, a four-digit numeric code to identify the paylist (PL) to which the employee was assigned.
SALARY RATE	Insert the employee's authorized basic salary on date of death (refer to Superannuation Administration manual (SAM) Section 6.2.5).
AUTHORIZATION DATE	Insert the effective date on which the salary reported in the previous block was authorized (refer to SAM Section 6.2.5).
ALLOWANCE RATE	Insert the total amount of any pensionable allowance(s) that the employee was receiving at date of death (refer to SAM Section 2.8.5).
AUTHORIZATION DATE	Insert the date on which the allowance(s) reported in the previous block were authorized. Note: Indicate the most recent date of authorization prior to the date of death, if more than one allowance is being reported.
COMPENSATION ADVISOR NAME OR DESIGNATED PERSON	Insert the full name of the employer representative or the designated person.
TELEPHONE NO.	Insert the area code and telephone number of the employer representative's office or the designated person.
FACSIMILE NO.	Insert the area code and facsimile number of the employer representative's office or the designated person.
SIGNATURE - COMPENSATION ADVISOR OR DESIGNATED PERSON	The employer representative or designated person signature must be added in this field.
DATE	Insert the date the form was completed.
CONTACT INFORMATION (CONTACT PERSON'S FULL NAME, ADDRESS AND RELATIONSHIP TO THE DECEASED)	Insert the contact information such as the full name, the complete address and the relationship to the deceased.
TELEPHONE NO.	Insert the area code and telephone number of the contact person.
ADDITIONAL INFORMATION	Insert additional information that may assist the Pension Centre in the counseling process such as date of memorial or funeral, preferred contact times, preferred communication method or additional contact person.

PART B: TO BE COMPLETED BY THE PAYING OFFICE (on demand from PSPC only)

Instructions to complete the information on LWOP

FIELD	INSTRUCTIONS
PERIOD OF LEAVE WITHOUT PAY	Insert the period of leave without pay (LWOP).
ARREARS ON DEATH BENEFIT CONTRIBUTION NOT RECOVERED	Insert the amount of outstanding SDB contributions that must be recovered. If there are no deficiencies, indicate "None" or "N/A". Only outstanding SDB deficiencies prior to November 2010 need to be reported.
AUTHORIZED OFFICER NAME	Insert the full name of the authorized officer.
SIGNATURE - AUTHORIZED OFFICER	The authorized officer signature must be added in this field.
DATE	Insert the date the PWGSC-TPSGC 2014 is certified.