PWGSC-TPSGC 2069 - Pensionable Employment Questionnaire

Protected "B" when completed

Pensionable Employment Questionnaire

Provision of the information requested on this document is voluntary. This information is being collected in accordance with the Public Service Superannuation Act (PSSA) for the purpose of electing to count under the PSSA a period of prior pensionable service with an outside employer. 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, employees have the right to request access to their personal information and to request corrections should they believe the information contains errors or omissions. Personal information provided about another individual may be accessible to that person under the Privacy Act. The records will be retained for two years following the last administrative action, and then will be destroyed.

This form must be completed electronically. If not possible, please use dark ink and capital letters.

Plan Member's Personal Information

Surname (required)

PRI (required)

Given Names (required)

Pension No. (required)

Date of Birth (YYYY-MM-DD) (required)

Preferred Language (required)

English

French

Preferred Telephone No. (required)

Home address (required)

Apartment No.

City (required)

Province (required)

Postal Code (required)

Country (required)

Email address (optional)

To: (name and address of employer outside the public service) (required)

Return to:

Public Service Pension Centre - Mail Facility
150 Dion Blvd
P.O. Box 8000
Matane QC G4W 4T6

Under the Public Service Superannuation Act, an employee may elect to count as pensionable service any qualifying period of employment with your organization which could have been counted upon becoming a member of your pension plan.

If pension records are not held in your office, forward this form to your pension plan administrator.

1. Release authorization of the employee (To be completed by employee)

To: (name and address of employer outside the public service) (required)

Employment Location (required)

Period of Employment

Period of Employment From (YYYY-MM-DD) (required)

Period of Employment To (YYYY-MM-DD) (required)

Reference Number (former employer)

Member telephone No.

I hereby authorize for release to the Public Service Pension Centre of Public Works and Government Services Canada, any information requested by this form regarding the time, duration and pensionable status of my former employment with your organization. I also authorize the release of information held by the pension plan administrator.

Signature of Employee

Date (YYYY-MM-DD) (required)

2. Particulars of Pension Plan (Sections 2 to 5 to be completed by plan administrator

1. State the official title of your pension plan

2. Was this person subject to your pension fund or plan during his employment?

Yes No

If no, go to Section 5 (Certification).

3. Please indicate below the registration date and registration number of your pension plan under the Canadian Income Tax Act.

The plan is not registered under the Income Tax Act (Please go to Section 5 (Certification)

Registration date (YYYY-MM-DD)

7 digit CRA registration number

4. The plan was:

Defined Benefit Plan (DB)

Money Purchase Plan/Defined Contribution (DC)

Hybrid Plan (greater benefit of DB and DC component)

Combination Plan (the sum of DB and DC components)

Deferred Profit Sharing Plan, Group RRSP or Pooled Registered Pension Plan (go to section 5 - Certification)

Other

(Please specify e.g.: Specified multi-employer pension plan (SMEPP)

3. Particulars of employment

1. Date of commencement of employment (YYYY-MM-DD)

2. Date of termination of employment (YYYY-MM-DD)

3. Date of plan membership (YYYY-MM-DD)

4. State the service credit for each pensionable year (including pre-1990 years) and pensionable earnings for post-89 years. If additional space is required, please attach a separate sheet. Attaching system printouts containing the information is acceptable. If you include service for which a pension benefit was received at some point in the past, but was not subsequently bought back, please attach the payout details, including date of payout on a separate sheet.

Year	Part time if applicable	Service from (Y-M-D)	Service to (Y-M-D)	Pensionable earnings (post-1989 years)¹	Pensionable service credit	PA/PSPA DB component²	PA DC component³







Total
1 - Please include deemed pensionable earnings for pensionable leave periods 2 - Compare if your plan is a Defined Benefit Plan (DB) or has a Defined Benefit component (ie. Combination Plan) 3 - Complete if your plan is a Defined Contribution Plan (DC) or has a Defined Contribution component (ie. Combination or Hybrid Plan)

5. If part-time employment was reported on the previous page, was the pensionable service credit reported as full-time equivalent service (the ratio equivalent to an employee working full-time)?

Yes No

6. If the member had part-time service which was not reported as full-time equivalent pensionable service, please provide, on a separate sheet, the hours worked each year and the standard full-time hours of the position. Attaching system printouts containing the information is acceptable.

7. Please list below all non-pensionable periods (i.e. non-pensionable leave, periods of unemployment, etc.). If the member was part of a Defined Contribution or Money Purchase provision, please list all periods of employment in respect of which no contribution was made on behalf of the member.

8. Was any service subject to a pension division as a result of a marriage breakdown?

If yes, please provide the affected period of service

From (YYYY-MM-DD)

To (YYYY-MM-DD)

If Yes, please provide the percentage of the division

4. Particulars of Pension Benefits Upon Termination of Employment

1. Date contributions ceased or pensionable service ceased to accrue (Y-M-D)

2. What benefit option was chosen by the member upon termination of employment?

(a) Return of Contributions

(b) Commuted Value

(specify type)

(d) Annual Pension

Effective Date (Y-M-D)

(e) No yet chosen

3. If the benefit was a type described in 2 (a), (b) or (c):

What date was the payment issued? (Y-M-D) Not Yet Paid

4. If the plan was underfunded at the time of payment, please indicate the solvency ratio.

5. Total amount of Commuted Value paid or payable (including any portion that remains to be paid)

What amount of the total sum indicated above represents the prescribed amount as per section 8517 of the Income Tax Regulations (locked-in portion)? What portion of the prescribed amount indicated above is in respect of post 1989 service?

6. If the payment has been made, was it transferred to:

RRSP

Defined Benefit Pension Plan

Money Purchase/Defined Contribution Pension Plan

Other (please specify)

7. What amount that remains to be paid because of a funding shortfall will be sent to a locked-in vehicle?

8. If any portion of the benefit remains or will remain to the employee's credit after payment described in 2 (a), (b) or (c), please complete the table below and indicate reason (ex. non-transferable, etc.)

From (Y-M-D)	To (Y-M-D)	Benefit type	Service credit	Reason benefit remains

5. Certification

The information provided in this questionnaire is certified to be correct

Authorized Signing Officer

Section 5 - Certification Date (Y-M-D)

Section 5 - Certification Telephone No.

Section 5 - Certification Facsimile No.

Section 5 - Certification Name and Title

Section 5 - Certification Email

For Office Use Only

Form No.

Office Use Only PRI

For Office Use Only Pension No.

PWGSC-TPSGC 2069 (09/2015)

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