PWGSC-TPSGC 571 - Enrolment Information and Acknowledgement of Plan Membership

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Enrolment Information and Acknowledgement of Plan Membership

Privacy notice

The personal information is collected on a voluntary basis pursuant to the Department of Public Works and Government Services Act sections 7(1)d) and 13. The personal information will be used by the Receiver General and Pension Branch of Public Services and Procurement Canada (PSPC) for the purpose of administrating the Public Service Superannuation Act (PSSA). The personal information is described in the Personal Information Bank Number PWGSC PCU 702—Federal pension administration. Your personal information is protected, used and disclosed in accordance with the Privacy Act. Under the Privacy Act, you have the right to access and correct your personal information, if erroneous or incomplete. The personal information provided in this application will be retained for a period of minimum 2 years after the last administrative action.

If you require clarification about this privacy notice, you may contact the Public Services and Procurement Canada’s Access to Information and Privacy Directorate by email at tpsgc.vieprivee-privacy.pwgsc@tpsgc-pwgsc.gc.ca. If you are not satisfied with the response to your privacy concern or if you want to file a complaint about the handling of your personal information, you may wish to contact the Office of the Privacy Commissioner of Canada.

Instructions: Complete all parts of this form. You can complete the form electronically and print it. Or you can print a blank form and fill it out in dark ink using capital letters. Sign and send your completed form to the Government of Canada Pension Centre.

Part 1—Plan member's personal information

Last name

First name

PRI no.

Plan Member's Personal Information Pension no.

Date of birth (YYYYMMDD)

Preferred language

English French

Telephone number

Home address

Apartment number

City

Province/Territory

Postal code

Country

Personal email address

Part 1—Plan members personal information (continued)

Work telephone number

Work email address (optional)

Part 2—Plan membership acknowledgment

Check the boxes below to let us know you’ve received, read and understood your Notification of Plan Membership (PWGSC-TPSGC 2018) form.

I’ve received and read my Notification of Plan Membership (PWGSC-TPSGC 2018) form.

I understand I’m a member of the public service pension plan.

I’ve read the information included with the form and understand I can obtain more information about my pension and benefits online.

I understand I may be entitled to buy back or transfer in past service to increase my public service pension credits. If I’m interested, I’m aware I should contact the Pension Centre in the first year of becoming a plan member. After this first year, any past service I may be eligible to buy or transfer may no longer be eligible or may cost significantly more.

If my department participates in the Supplementary Death Benefit (SDB) plan, I understand I can name or change SDB beneficiaries at any time by completing the Naming or Changing Your Beneficiaries (PWGSC-TPSGC 2196E) form, or online using My GC Pension (currently available to most members).

Note: You can’t have more than 35 years of pensionable service to your credit under the public service pension plan. This 35-years maximum includes pensionable services to your credit under other federal government pension plans (such as the Canadian Armed Forces and Royal Canadian Mounted Police pension plans).

For office use only

Form no.

Case no.

For office use PRI

For office use Pension no.

Part 3—Plan member’s eligible dependents

To help us determine if you have eligible dependents, provide the full name and date of birth of your married spouse or common-law partner and your children under the age of 25.

Note: You’re required to send us proof of your marital status and proof of age for your children (photocopies are accepted).

Marital status

Marital status

Single

Married

Widowed

Divorced

Separated

Common-law

Identify the following if applicable:	First and last name	Date of birth (YYYY-MM-DD)
Married spouse or common-law partner	First and last name Married spouse or common-law partner	Date of birth Married spouse or common-law partner (YYYY-MM-DD)
Child 1 under age 25	First and last name Child 1	Date of birth Child 1 (YYYY-MM-DD)
Child 2 under age 25	First and last name Child 2	Date of birth Child 2 (YYYY-MM-DD)
Child 3 under age 25	First and last name Child 3	Date of birth Child 3 (YYYY-MM-DD)
Child 4 under age 25	First and last name Child 4	Date of birth Child 4 (YYYY-MM-DD)
Child 5 under age 25	First and last name Child 5	Date of birth Child 5 (YYYY-MM-DD)

Attach a separate sheet if space is insufficient

Part 4—Signature and date

Signature

Date (YYYY-MM-DD)

Mail of fax your completed form to:

Government of Canada Pension Centre—Mail Facility
150 Dion Blvd
PO Box 8000
Matane, QC G4W 4T6

Fax: 1-418-566-6298

Questions?

If you have questions about this form or the information it contains, we can help.

Call us at 1-800-561-7930 (toll-free).

Find forms and more information on our website.

PWGSC-TPSGC 571E (2024-04-18)

Date modified:: 2024-08-08