PWGSC-TPSGC 2014 - Notification of Death In Service

PDF Version (216Kb) Help on Alternative Formats

Protected "B" when completed

Notification of Death In Service

Provision of the information requested on this form may be used for the purpose of providing pertinent information to issue the Supplementary Death Benefit payment under the Public Service Superannuation Act (PSSA). This personal information will be stored in Personal Information Bank Number PWGSC PCE 702 and is protected from disclosure to unauthorized persons/agencies pursuant to the provisions of the Privacy Act. Under the Act, you have the right to request access to your personal information, held by a federal government institution, and to request corrections should you believe the information contains errors or omissions. Personal information that you provide about another individual may be accessible to that person under the Privacy Act. The information will be retained by the Department for two years following the last administrative change and then destroyed.

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

Plan Member's Personal Information

Surname

PRI

Given Names

Plan Member's Personal Information 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)

Part A - To be completed by the Compensation Advisor or designated person.

Date of Death (Y-M-D)

Department

Salary Rate (See note on next page)

Salary Rate Authorization Date (Y-M-D)

Allowance Rate (See note on next page)

Allowance Rate Authorization Date (Y-M-D)

Compensation Advisor Name or Designated Person (print)

Tel. No. of Compensation Advisor

Fascimile No.

Signature - Compensation Advisor or Designated Person

Compensation Advisor Signature Date (Y-M-D)

Contact Information

Full Name

Contact information Telephone No.

Address

Relationship to the Deceased

Additional Information

Part B - To be completed by the paying office (on demand from PSPC only).

1. Period of Leave Without Pay

1. Period of Leave Without Pay From (Y-M-D)

1. Period of Leave Without Pay To (Y-M-D)

2. Arrears on Death Benefit Contributions Not Recovered

Authorized Officer Name (print)

Signature - Authorized Officer

Pay office signature Date (Y-M-D)

Original: Public Service Pension Centre - Mail Facility
Copies:
1. Pay Office
2. Personnel Office

For Office Use Only

Form No.

Case No.

For Office Use Only PRI

For Office Use Only Pension No.

Instructions

Part A

This form must be completed by Departments, Crown Corporations and Agencies when an employee who is a participant under the public service pension plan dies in service.
The salary and allowance rates for a part-time plan member are prorated based on the average Assigned Work Week (AWW).
For the contact information enter the full name, address, telephone number and the relationship to the deceased. Additional information can also be provided such as date of memorial or funeral, preferred contact times, preferred communication method or additional contact person.
The Compensation Advisor or the designated person must complete Part A of this form and fax the original immediately to the Public Service Pension Centre.

Part B

The paying office must complete Part B when requested by Public Service Pension Centre (PSPC). The completed form must be sent by fax to the PSPC within 24 hours. If there are no deficiencies, indicate "None or N/A".
Only outstanding SDB deficiencies for periods of Leave Without Pay (LWOP) ending prior to December 2011 need to be reported.

PWGSC-TPSGC 2014 (05/2011)