Public Services and Procurement Canada
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Protected "B" when completed
Provision of the information requested on this document is voluntary. This information is being collected in accordance with the Public Service Superannuation Act (PSSA) for the administration of entitlement to a student's allowance under the 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, 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 use dark ink and capital letters.
You must be presently enrolled as a full-time student at an educational institute before completing Section A of this declaration, and Section B can only be completed, signed and dated after the commencement of the academic year.
If you are applying for an allowance for the first time, complete a declaration for each educational institute attended since attaining age 18 or since the plan member's death, whichever is later.
Please enclose your birth certificate, if you have not already submitted it to Public Service Pension Centre.
Send completed declarations to:
Public Works and Government Services Canada Public Service Pension Centre - Mail Facility 150 Dion Blvd PO Box 8000 Matane QC G4W 4T6
If you have not attende any educational institute since attaining age 18 or since the plan member's date of death, whichever occurred later, please attach a statement giving the duration and reasons for any absence.
Full duration (e.g. Sept. 1989 to April 1993)
Current Semester or Academic Year (e.g. Sept. 1989 to April 1990)
I hereby declare that, to the best of my knowledge and belief, the information given above is true and complete and I undertake to notify the Director of Public Service Pension Centre should I interrupt or terminate attendance at the educational institute noted in Section B. I hereby authorize the said educational institute to provide the Director of Superannuation, Pension Transition and Client Services Sector with information regarding my enrollment and attendance.
It is an offence to make a false or misleading statement in this declaration.
To the best of our knowledge and belief, the answers in Section A are correct except as noted hereunder.
Note to Institute: This section must only be completed, signed and dated after the student completes all appropriate areas in Section A and after the actual attendance commenced.
Authorized for payment under the provisions of the Public Service Superannuation Act (PSSA). Requisitioned pursuant to section 33 and 34 of the Financial Administration Act for continuing payment until advised otherwise and certified in accordance with Treasury Board comptrollership policies on account verification.
The Public Service Superannuation Act provides that dependant children of certain deceased plan members can receive an allowance beyond age 18 if the following conditions are met.
The dependant child of a plan member must be:
A substantial interruption is one which necessitates a withdrawal from school or delays enrollment. Short periods of illness and regular scholastic vacations do not constitute substantial interruptions in attendance. The circumstances of a substantial interruption must be outlined in the declaration on the reverse side of this form and will be examined by the director in order to determine if they justify initiating or reinstating payment of an allowance.
NOTE: Under no circumstances will entitlement to an allowance be established or reinstated:
Where the director is satisfied that a student meets the conditions of entitlement, payment will be made directly to the student. The amount of the allowance will depend on the salary and length of pensionable service of the deceased plan member and possibly the number of dependant children entitled to an allowance.
Where a dependant student is deemed to be entitled to an allowance, payment will commence with effect from the later of:
The payment will continue until the end of the month in which the current academic year ends. Payment will recommence for the following academic year upon receipt of a properly completed declaration of attendance. This form will be issued each year to those individuals currently receiving an allowance. Additional forms will be supplied on request.
Payment will be made on a retroactive basis for regular vacation periods, periods of illness, or other approved absences only if the dependant child commences or resumes full-time attendance at school immediately.
Entitlement to an allowance will terminate when the dependant child ceases attendance or attains age 25 during the academic year. Payments will cease at the end of the month in which such an event occurs.
when any of the following events occur:
NOTE: The school official must sign the declaration on the reverse side only after the dependant student completes all appropriate areas in Section A. The form should also bear the official stamp or seal of the educational institute.
PWGSC-TPSGC 2002 (09/2009)
