PWGSC-TPSGC 2201 - Request to Certify a Salary Rate

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Request to Certify a Salary Rate

This information is being collected in accordance with the Public Service Superannuation Act (PSSA) to process a service buyback request from the plan member. 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, the employee has the right to request access to his/her personal information and to request corrections should he/she 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 records will be retained by the department for two years following the last administration action, and then will be 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)

Carefully read instructions before completing.

From:

Public Service Pension Centre

Name

Telephone Number

Fax No.

Department

Pay Office

Paylist

Date (Y-M-D)

Please state the full-time equivalent salary and allowance rate, standard work week, assigned work week (if applicable) for date(s) indicated below.

Salary Rate - Line 1 Date (Y-M-D)

^{Footnote *}Hourly, Daily, Weekly, Monthly, Annually

Salary Rate - Line 1 Salary Rate

Allowance Rate - Line 1 Allowance Rate

Standard Work Week

Standard Work Week - Line 1 Hours

Assigned Work Week

Assigned Work Week - Line 1 Hours

Date of the collective agreement - Line 1 Date of the collective agreement, TB Minute or arbitral award applicable to the salary rate shown.

Salary Rate - Line 2 Date (Y-M-D)

^{Footnote *}Hourly, Daily, Weekly, Monthly, Annually

Salary Rate - Line 2 Salary Rate

Allowance Rate - Line 2 Allowance Rate

Standard Work Week

Standard Work Week - Line 2 Hours

Assigned Work Week

Assigned Work Week - Line 2 Hours

Date of the collective agreement - Line 2 Date of the collective agreement, TB Minute or arbitral award applicable to the salary rate shown.

Salary Rate - Line 3 Date (Y-M-D)

^{Footnote *}Hourly, Daily, Weekly, Monthly, Annually

Salary Rate - Line 3 Salary Rate

Allowance Rate - Line 3 Allowance Rate

Standard Work Week

Standard Work Week - Line 3 Hours

Assigned Work Week

Assigned Work Week - Line 3 Hours

Date of the collective agreement - Line 3 Date of the collective agreement, TB Minute or arbitral award applicable to the salary rate shown.

Salary Rate - Line 4 Date (Y-M-D)

^{Footnote *}Hourly, Daily, Weekly, Monthly, Annually

Salary Rate - Line 4 Salary Rate

Allowance Rate - Line 4 Allowance Rate

Standard Work Week

Standard Work Week - Line 4 Hours

Assigned Work Week

Assigned Work Week - Line 4 Hours

Date of the collective agreement - Line 4 Date of the collective agreement, TB Minute or arbitral award applicable to the salary rate shown.

Salary Rate - Line 5 Date (Y-M-D)

^{Footnote *}Hourly, Daily, Weekly, Monthly, Annually

Salary Rate - Line 5 Salary Rate

Allowance Rate - Line 5 Allowance Rate

Standard Work Week

Standard Work Week - Line 5 Hours

Assigned Work Week

Assigned Work Week - Line 5 Hours

Date of the collective agreement - Line 5 Date of the collective agreement, TB Minute or arbitral award applicable to the salary rate shown.

Certified by

Certified by Name

Certified by Tel. No.

Certified by Fax. No.

Signature

Certified by Date (Y-M-D)

Note:

This form should be completed when there is a discrepancy with a previously certified salary or salary information contained in the pension system. A clarification of the discrepancy would be required.

Promotions and salary revisions authorized retroactively after the date indicated do not apply for the purpose of calculating the cost of a service buyback.

Salary amendments paid after the date indicated but authorized prior to that date must be used.

Salary and allowance rates must conform to one of the five pay methods.

For Office Use Only

Form No.

Case No.

For Office Use Only PRI

For Office Use Only Pension No.

Footnotes

Footnote 1

Salary and allowance rates must conform to one of the five pay methods.

Return to first footnote * referrer

PWGSC-TPSGC 2201 (09/2009)