PWGSC-TPSGC 570 - Service Buyback Payment Transmittal for Plan Member on Leave Without Pay

Protected "B" when completed

Service Buyback Payment Transmittal for Plan Member on Leave Without Pay

Provision of the information requested on this document is voluntary. The information is being collected in accordance with the Public Service Superannuation Act (PSSA) for the purpose of remitting payments in respect of a leave without pay period and/or a service buyback. This personal information will be stored in Personal Information Bank Number PWGSC PCU 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

Carefully read instructions before completing.

This form is used by the plan member for the purpose of remitting payments in respect of a period of leave without pay and/or a service buyback. This form provides information necessary for accounting purposes.

Send the completed form to the following address together with your payment:

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

Cash payments such as personal cheques and money orders must be made payable to the Receiver General for Canada.

If sending a payment in respect of more than one service buyback, indicate the total of the monthly deduction amount for all service buybacks.

If your payment is made through a direct transfer of funds from a Registered Retirement Savings Plan (RRSP), complete and attach the Canada Revenue Agency form T2033 to this form (in lieu of a cheque
or money order).

Note: In Part C of the form T2033 indicate "0288795" for the CRA registration number and "Public Service
Superannuation Account" for the RPP name.

Residents of Ontario and Québec must add the provincial sales tax to the amount of Supplementary Death Benefit (SDB) contributions, 8% for Ontario and 9% for Québec.

Payment Information

This payment covers the following month(s):

For Office Use Only

PWGSC-TPSGC 570 (09/2009)