PWGSC-TPSGC 2347-18 - Certification of Lock-In For Purposes of the Public Service Superannuation Act or the Pension Benefits Division Act

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Certification of Lock-In For Purposes of the Public Service Superannuation Act or the Pension Benefits Division Act

Provision of the information requested on this document is voluntary. This information is being collected for the purpose of certifying lock-in provisions in accordance with the Public Service Superannuation Act (PSSA) or the Pension Benefits Division Act (PBDA). 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 this 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 by the department for two years following the last administrative 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

Plan Member's Personal Information PRI

Given Names

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 on the following page before completing.

Name of Payee

Social Insurance No.

Account No.
(see instruction No. 2)

We certify that the above-named individual's account to which the funds payable pursuant to the PSSA or the PBDA are to be credited meets one of the following requirements:

the funds will be administered in accordance with the lock-in provisions of the federal Pension Benefits Standards Act, 1985;

the funds will be used for the purchase of an immediate or deferred life annuity, as defined in the federal Pension Benefits Standards Act, 1985 for the above-named individual.

Name and Address of Company or Financial Institution

Company or Financial Institution Stamp, Seal or Address Stamp

Signature of Official

Position Title

Name

Date (Y-M-D)

Tel. No.

Fax. No.

For Office Use Only

Form No.

Case No.

PRI

For Office Use Only Pension No.

Instructions

Pursuant to the provisions of the Privacy Act, information regarding the payee's pension account will not be given to the company or financial institution unless the payee provides the Public Service Pension Centre with a written authorization to release that informations.
The "Account No.", under which the funds will be locked-in, must correspond to the account number quoted on the Canada Revenue Agency (CRA) form used for the direct transfer of funds (T2151E). Should the number on the CRA form differ, the payee should amend the form accordingly.
Questions concerning the lock-in provision under the federal Pension Benefits Standards Act, 1985 (PBSA, 1985) must be addressed to the company or institution's regional office or head office. Should that office be unable to reply to the inquiry, information about the PBSA can be obtained from the Office of the Chief Actuary (OCA).
If the address where the funds must be transferred differs from the address on this form, please indicate the correct address for payment on a separate sheet.
If the company or financial institution has no stamp, seal or address stamp, a letter with the company or institution's letterhead must accompany this form.
The original copy of this form must be forwarded to the Public Service Pension Centre by the payee, the company or the financial institution.

Public Service Pension Centre
Mail Facility
150 Dion Blvd
PO Box 8000
Matane QC G4W 4T6

PWGSC-TPSGC 2347-18 (04/2010)