PWGSC-TPSGC 2001-1 - Elective Pensionable Service Record for Operational Service

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Elective Pensionable Service Record for Operational Service

Provision of the information requested on this form is voluntary. This information is being collected in accordance with the Public Service Superannuation Act (PSSA) for the purpose of acquiring an estimate of cost or a buyback for a period of non-contributory service. 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 last administrative action, and then will be destroyed.

This form must be completed electronically. If not possible, please use dark ink and capital letters.

Plan Member's Personal Information

Preferred Language
Preferred Language

Note: Refer to the Instructions on how to complete parts 1 and 2.

1 - Employment - Note: All columns must be completed

Periods of EmploymentLine 1

Length of Period Line 1

Sch. Work Week (SWW)

Assigned Work Week (AWW)

Nature of Tenure Classification

Line 1 Leave without Pay

Length of LWOP Line 1

Reason for LWOP

Periods of EmploymentLine 2

Length of Period Line 2

Sch. Work Week (SWW)

Assigned Work Week (AWW)

Nature of Tenure Classification

Line 2 Leave without Pay

Length of LWOP Line 2

Reason for LWOP

Periods of EmploymentLine 3

Length of Period Line 3

Sch. Work Week (SWW)

Assigned Work Week (AWW)

Nature of Tenure Classification

Leave without Pay Line 3

Length of LWOP Line 3

Reason for LWOP

Periods of Employment Line 4

Length of Period Line 4

Sch. Work Week (SWW)

Assigned Work Week (AWW)

Nature of Tenure Classification

Leave without Pay Line 4

Length of LWOP Line 4

Reason for LWOP

Periods of EmploymentLine 5

Length of Period Line 5

Sch. Work Week (SWW)

Assigned Work Week (AWW)

Nature of Tenure Classification

Leave without Pay Line 5

Length of LWOP Line 5

Reason for LWOP

Periods of EmploymentLine 6

Length of Period Line 6

Sch. Work Week (SWW)

Assigned Work Week (AWW)

Nature of Tenure Classification

Leave without Pay Line 6

Length of LWOP Line 6

Reason for LWOP

2 - Pensionable Earnings for Post 1989 Service for Each Calendar Year

Note: Report pensionable earnings (excluding overtime salary and non-superannuable allowances) received in each calendar year beginning January 1, 1990 , but only in conjunction with the above-mentioned periods of service.

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

I certify that this is an accurate transcript of official records.

For Office Use Only

Instructions

Part 1: Employment

  1. Periods of Employment: Indicate the "FROM" and "TO" dates of employment in (YYYYMMDD) format.
  2. Length of Period: Indicate the number of months and days contained in the period of employment.
  3. Scheduled Hours of Work (SWW): Indicate the number of hours in a week that the employee was required to work.
  4. Assigned work week (AWW): Indicate the number of hours that the employee actually worked in a week.
  5. Nature of tenure Classification: Indicate the type of appointment for the period of employment:
    • Indeterminate
    • T - Term or Casual
    • S - Seasonal
    • O - Other
  6. Leave Without Pay (LWOP): Indicate the "FROM" and "TO" date of the period of LWOP in (YYYYMMDD) format.
  7. Length of LWOP: Indicate the number of months and days contained in the period of LWOP.
  8. Reason for LWOP: Indicate the reason for the LWOP (maternity, relocation of spouse, sick leave, etc).

Part 2: Pensionable Earnings for Post 1989 Service

  1. From / To: Indicate for each calendar year in (YYYYMMDD) format, the "FROM" and "TO" dates in which Post 1989 pensionable earnings were received.
  2. Pensionable Earnings: Indicate the amount of pensionable earnings received in each year corresponding to the employment period.

Note: The pensionable earnings will be utilized by Public Service Pension Centre to calculate the PSPA.

PWGSC-TPSGC 2001-1 (09/2009)