PWGSC-TPSGC 2486 - Application for Division of a Public Service Superannuation Act Pension Benefits in Accordance with the Pension Benefits Division Act

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Application for Division of a Public Service Superannuation Act Pension Benefits in Accordance with the Pension Benefits Division Act

Provision of the information requested on this document is required by law in accordance with the Pension Benefits Division Act (PBDA) for the purpose of an application for division of a 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 this 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 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 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

PRI

Given Names

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)

A. Plan Member

Current or former spouse/common-law partner of plan member

Department

Location

Human Resources Contact Person

Telephone No.

B. Current or Former Spouse/Common-Law Partner of Plan Member

Current or Former Spouse Surname

Current or Former Spouse Given Names

SIN

Current or Former SpouseHome Address

C. Applicant

I am applying as the

applicant Plan Member

applicant Current or former spouse/common-law partner of the plan member

Personal representative of the

representative of Plan Member

representative of Current or former spouse/common-law partner of the plan member

D. Supporting Documents

Supporting Documents

supporting documents selection 1 Court order (certified by the Clerk of the Court), or original or certified true copy of the written agreement providing for the division of the plan member's Public Service Superannuation Act pension benefits

Original or certified true copy of other document (if applicable) that authorizes a personal representative to act on behalf of the plan member, or the current or former spouse/common-law partner

Statutory Declaration PWGSC-TPSGC 2484

Copy of the marriage certificate (if applicable)

Copy of the death certificate of the plan member, or the current or former spouse/common-law partner (if applicable)

E. Applicant's Signature

I hereby apply for the division of the pension benefits accrued to the plan member named herein under the Public Service Superannuation Act in accordance with the Pension Benefits Division Act.

Applicant's Signature

Applicant's Date (Y-M-D)

Applicant section Telephone No.

The completed application and supporting documents are to be returned to:

Public Works and Government Services Canada
Public Service Pension Centre - Mail Facility
150 Dion Blvd
PO Box 8000
Matane QC G4W 4T6

NOTE: Every person who knowingly makes a false or misleading representation in any application or other proceeding under the Pension Benefits Division Act is guilty of an offence punishable on summary conviction.

For Office Use Only

Form No.

Case No.

For Office Use Only PRI

For Office Use Only Pension No.

PWGSC-TPSGC 2486 (09/2009)