PWGSC-TPSGC 2016 - Statutory Declaration

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Pension No.

Statutory Declaration

Provision of the information requested on this form may be used for the purpose of declaring the existence of a common-law relationship under the Public Service Superannuation Act (PSSA). 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 the Act, you have the right to request access to your personal information 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 administration change and then destroyed.

,
(Name of declarant)

,
(City/Town)

Province/Territory

,
(Province/Territory)

Do solemnly declare that:

I have been living in a common-law relationship with

Name of Common-law Spouse/Partner

,
(Name of Common-law Spouse/Partner)

since

,
(Y-M-D)

and that should there be a change in this status, I will notify Public Service Pension Centre immediately.

And, I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

Signature of Declarant

(Signature of Declarant)

Declared before me at

Declarant City/Town

,
(City/Town)

Declarant Province/Territory

,
(Province/Territory)

this

,
(Day)

Declarant day of

,
(Month)

Declarant Years

,
(Year)

Commissioner of Oaths, Notary Public, Justice of the Peace

,
(Commissioner of Oaths, Notary Public, Justice of the Peace)

My commission expires on the

,
(Day)

day of

,
(Month)

Expiry Year

.
(Year)

PWGSC-TPSGC 2016 (09/2009)