PWGSC-TPSGC 2123 - Certification of Leave Without Pay

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Certification of Leave Without Pay

Provision of the information requested on this document is voluntary and is required to comply with the provisions of the Public Service Superannuation Act (PSSA). The personal information is collected for the purpose of reporting leave without pay which occurred during a period of prior elective pensionable service and is important to making a decision directly affecting the employee's pension. Non-completion of this form may result in incorrect pension estimates and statements. The information is maintained in Personal Information Bank Number PWGSC PCE 702 (Public Service Pensions Data Bank) and is protected from disclosure in accordance with the provisions of the Privacy Act. Under this Act, the employee has the right to request access and correction of his personal information, if erroneous or incomplete. The records are retained for two years following the last administrative action 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.

Date of Birth (YYYYMMDD)

Preferred Language

English French

Preferred Telephone No.

Home address

Apartment No.

City

Province

Postal Code

Country

Email address (optional)

Instructions:

This form is to be completed by the employing department or agency to report periods of authorized or unauthorized leave without pay, strike and suspension which occurred during prior contributory service which the plan member has chosen to count as pensionable service under the terms of the PSSA. It is also required for all buybacks for prior contributory public service that occurred on and after January 1, 1990 for which a lump sum benefit, such as a return of contributions (ROC), was paid upon termination of employment, regardless if the plan member was on leave without pay, strike and suspension during that time. Upon completion, this form is to be forwarded to the Public Service Pension Centre.

Section A - To identify the plan member's employing department during a specific period of elective service

Department

Paylist

Employee No.

Period of Elective Service

Section A Line 1 Department Name

Section A Line 1 From (Y-M-D)

Section A Line 1 To (Y-M-D)

Section A Line 1 AWW

Section A Line 1 SWW

Section A Line 2 Department Name

Section A Line 2 From (Y-M-D)

Section A Line 2 To (Y-M-D)

Section A Line 2 AWW

Section A Line 2 SWW

Section A Line 3 Department Name

Section A Line 3 From (Y-M-D)

Section A Line 3 To (Y-M-D)

Section A Line 3 AWW

Section A Line 3 SWW

Section A Line 4 Department Name

Section A Line 4 From (Y-M-D)

Section A Line 4 To (Y-M-D)

Section A Line 4 AWW

Section A Line 4 SWW

Section A Line 5 Department Name

Section A Line 5 From (Y-M-D)

Section A Line 5 To (Y-M-D)

Section A Line 5 AWW

Section A Line 5 SWW

Leave Without Pay (LWOP)

Section B - To identify the period of Leave of without pay (LWOP) which occurred during prior contributory service

Period(s) of pensionable LWOP

Period(s) of pensionable LWOP - Line 1 From (Y-M-D)

Period(s) of pensionable LWOP - Line 1 To (Y-M-D)

Period(s) of pensionable LWOP - Line 1 Reason Code

Period(s) of pensionable LWOP - Line 2 From (Y-M-D)

Period(s) of pensionable LWOP - Line 2 To (Y-M-D)

Period(s) of pensionable LWOP - Line 2 Reason Code

Period(s) of pensionable LWOP - Line 3 From (Y-M-D)

Period(s) of pensionable LWOP - Line 3 To (Y-M-D)

Period(s) of pensionable LWOP - Line 3 Reason Code

Period(s) of pensionable LWOP - Line 4 From (Y-M-D)

Period(s) of pensionable LWOP - Line 4 To (Y-M-D)

Period(s) of pensionable LWOP - Line 4 Reason Code

Period(s) of pensionable LWOP - Line 5 From (Y-M-D)

Period(s) of pensionable LWOP - Line 5 To (Y-M-D)

Period(s) of pensionable LWOP - Line 5 Reason Code

Period(s) of pensionable LWOP - Line 6 From (Y-M-D)

Period(s) of pensionable LWOP - Line 6 To (Y-M-D)

Period(s) of pensionable LWOP - Line 6 Reason Code

Section C - To identify the periods of service where the employee has previously opted not to count LWOP as pensionable service

Option not to count LWOP as pensionable service

Section C Line 1 From (Y-M-D)

Section C Line 1 To (Y-M-D)

Section C Line 1 Reason Code

Section C Line 1 PA Reported (Yes/No)

Section C Line 1 Calendar Years (specify calendar years)

Section C Line 2 From (Y-M-D)

Section C Line 2 To (Y-M-D)

Section C Line 2 Reason Code

Section C Line 2 PA Reported (Yes/No)

Section C Line 2 Calendar Years (specify calendar years)

Section C Line 3 From (Y-M-D)

Section C Line 3 To (Y-M-D)

Section C Line 3 Reason Code

Section C Line 3 PA Reported (Yes/No)

Section C Line 3 Calendar Years (specify calendar years)

Section C Line 4 From (Y-M-D)

Section C Line 4 To (Y-M-D)

Section C Line 4 Reason Code

Section C Line 4 PA Reported (Yes/No)

Section C Line 4 Calendar Years (specify calendar years)

Section C Line 5 From (Y-M-D)

Section C Line 5 To (Y-M-D)

Section C Line 5 Reason Code

Section C Line 5 PA Reported (Yes/No)

Section C Line 5 Calendar Years (specify calendar years)

Section C Reason Codes

Maternity
Personal
Illness
Education leave
Parental leave
The period of LWOP consists of CSC operational service (please specify in Section G if the leave was at single or double rate of contribution)
Other (please specify in Section G)

Section D - To identify periods of non-pensionable service which occurred during prior contributory service and which will never be elective

Non-pensionable Service

Section D Line 1 From (Y-M-D)

Section D Line 1 To (Y-M-D)

Section D Line 1 Reason Code

Section D Line 2 From (Y-M-D)

Section D Line 2 To (Y-M-D)

Section D Line 2 Reason Code

Section D Line 3 From (Y-M-D)

Section D Line 3 To (Y-M-D)

Section D Line 3 Reason Code

Section D Line 4 From (Y-M-D)

Section D Line 4 To (Y-M-D)

Section D Line 4 Reason Code

Section D Line 5 From (Y-M-D)

Section D Line 5 To (Y-M-D)

Section D Line 5 Reason Code

Section D Line 6 From (Y-M-D)

Section D Line 6 To (Y-M-D)

Section D Line 6 Reason Code

Section D Reason Codes

Unauthorized leave without pay
Suspension
Strike
Sessional or seasonal layoff
LWOP exceeding the 5-year limit permissible
Other (please specify in Section G)

Section E - Completion of this section is not required if the return of contributions was paid prior to January 1, 1997

Pensionable earnings for post-1989 service for each calendar year

NOTE: Report pensionable earnings (excluding overtime salary and non-superannuable allowances) for each payroll calendar year beginning January 1, 1990, but only in correspondence with the above-mentioned periods of services under Section A.

Section E Line 1 From (Y-M-D)

Section E Line 1 To (Y-M-D)

Section E Line 1 Pensionable Earnings

Section E Line 2 From (Y-M-D)

Section E Line 2 To (Y-M-D)

Section E Line 2 Pensionable Earnings

Section E Line 3 From (Y-M-D)

Section E Line 3 To (Y-M-D)

Section E Line 3 Pensionable Earnings

Section E Line 4 From (Y-M-D)

Section E Line 4 To (Y-M-D)

Section E Line 4 Pensionable Earnings

Section E Line 5 From (Y-M-D)

Section E Line 5 To (Y-M-D)

Section E Line 5 Pensionable Earnings

Section E Line 6 From (Y-M-D)

Section E Line 6 To (Y-M-D)

Section E Line 6 Pensionable Earnings

Section E Line 7 From (Y-M-D)

Section E Line 7 To (Y-M-D)

Section E Line 7 Pensionable Earnings

Section E Line 8 From (Y-M-D)

Section E Line 8 To (Y-M-D)

Section E Line 8 Pensionable Earnings

Section E Line 9 From (Y-M-D)

Section E Line 9 To (Y-M-D)

Section E Line 9 Pensionable Earnings

Section E Line 10 From (Y-M-D)

Section E Line 10 To (Y-M-D)

Section E Line 10 Pensionable Earnings

Section E Line 11 From (Y-M-D)

Section E Line 11 To (Y-M-D)

Section E Line 11 Pensionable Earnings

Section E Line 12 From (Y-M-D)

Section E Line 12 To (Y-M-D)

Section E Line 12 Pensionable Earnings

Section E Line 13 From (Y-M-D)

Section E Line 13 To (Y-M-D)

Section E Line 13 Pensionable Earnings

Section E Line 14 From (Y-M-D)

Section E Line 14 To (Y-M-D)

Section E Line 14 Pensionable Earnings

Section E Line 15 From (Y-M-D)

Section E Line 15 To (Y-M-D)

Section E Line 15 Pensionable Earnings

Section E Line 16 From (Y-M-D)

Section E Line 16 To (Y-M-D)

Section E Line 16 Pensionable Earnings

Section E Line 17 From (Y-M-D)

Section E Line 17 To (Y-M-D)

Section E Line 17 Pensionable Earnings

Section E Line 18 From (Y-M-D)

Section E Line 18 To (Y-M-D)

Section E Line 18 Pensionable Earnings

Section F

Payment date of ROC (Y-M-D)

Was the ROC paid in cash?

Yes No

If no, was it transferred to

RRSP

Registered Pension Plan

Other (specify in Section G)

What portion of the ROC applies to service which occurred after December 31, 1989?

Section F Question 3 Amount

Section G - Provide additional information associated with the periods being certified and/or identified in sections B, C and D

Section G Remarks

Section H

I certify that the above data accurately reflects the information contained in the appropriate official records.

Section H Name of Compensation Advisor

Section H Signature

Section H Date (Y-M-D)

Section H Tel. No.

Section H Facsimile No.

Section H Email Address

For Office Use Only

Form No.

Case No.

For Office Use Only PRI

For Office Use Only Pension No.

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

PWGSC-TPSGC 2123 (09/2009)