PWGSC-TPSGC 2460: Application for diversion from a public service pension

Privacy notice

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 purpose of pension diversion. 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 the 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 that you provide 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.

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Instructions for fillable PDF forms

Plan member's personal information

Surname

Plan Member's Personal Information PRI

Given Names

Plan Member's Personal Information 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)

Please provide the following information concerning the recipient of the pension benefit.

Most recent known and most recent known year at this address

Year (Y-M-D)

Annuity Number (if known)

Previous Family Name (if applicable)

Recipient Postal Code

Recipient Year (Y-M-D)

Most recent place of employment in the Public Service and most recent year at that place (if known)

Place: Department/Branch/Division

Place: Department/Branch/Division Year (Y-M-D)

Check the applicable acts or regulations under which the recipient is entitled to a pension (if known)

Governor General's Act

Lieutenant Governors' Superannuation Act

Members of Parliament Retiring Allowances Act

Judges Act

Public Service Superannuation Act

Royal Canadian Mounted Police Superannuation Act, Part 1

Royal Canadian Mounted Police Pension Continuation Act, Parts II and III

Special Retirement Arrangements Act

Regulations made by the Governor in Council or the Treasury Board that, in the opinion of the Minister, provide for the payment out of the Consolidated Revenue Fund of a pension to be charged to the Public Service Superannuation Account that is calculated on the basis of length of service of the person to or in respect of whom it was granted or is payable

Currency, Mint and Exchange Fund Act, subsection 15(2), R.S.C. 1952, C. 315

An Appropriation Act of the Parliament of Canada that, in the opinion of the Minister, provides for the payment of a pension calculated on the basis of length of service of the person to or in respect of whom it was granted or is payable

War Veterans Allowance Act, subsection 28(10)

Regulations made under Vote 181 of Appropriation Act No. 5, 1961

Civil Service Superannuation Act

Canadian Forces Superannuation Act

Defence Services Pension Continuation Act

Diplomatic Service (Special) Superannuation Act

Tax Court of Canada Act

Please provide any other information which may help to identify the recipient.

Other Information

Please provide the following information concerning the applicant (the person named in the court order as being entitled to financial support).

Person Named in Court Order (Given Names and Surname)

Person Named in Court Order (Given Names and Surname) Date of Birth (Y-M-D)

Present Mailing Address

Person Named in Court Order (Given Names and Surname) Postal Code

Will the applicant have custody and control of another person entitled to financial support from the recipient?

Yes

No

If yes, please indicate name and address.

Given Name and Surname

Custody and Control Address

Custody and Control Postal Code

Will the applicant have someone acting on his/her behalf (e.g. a lawyer)?

Lawyer Yes

Lawyer No

If yes, please indicate full name, and address, and their legal relationship.

Lawyer Given Name and Surname

Lawyer Legal Relationship

Lawyer Address

Lawyer Postal Code

Is this form being completed by the acting person?

Acting Yes

Acting No

Diversion payment made to a person other than the applicant (e.g. family court). Identify the person named in the financial support order.

Diversion Given Name and Surname

Diversion Address

Diversion Postal Code

Documentation

The original or certified true copy of the financial support order under which this application is made must be attached.

If the name on the financial support order is not the same as the name of the applicant (identified on the previous page), then you must provide either:

a certified copy of the certificate evidencing the change where a formal change of name has occurred
or
a statutory declaration by the person making this application as to the circumstances concerning the difference in any other case.

If the name on the financial support order is the same as the name of the applicant (identified on the previous page) and this person is a child then you must provide:

a child birth certificate
or
a certified true copy of proof of birth

Authorization

I hereby request the Minister of Public Works and Government Services Canada to divert from the recipient's net pension benefit an amount calculated in accordance with the provisions of the "Garnishment, Attachment and Pension Diversion Act" and Regulations.

Signature of Applicant or Representative

Date (Y-M-D)

Signature of Applicant or Representative:

Note: Mail the completed application to:

Departmental General Counsel
Public Works and Government Services Canada
Phase III, 1C2, Place du Portage
Gatineau QC K1A 0S5

For office use only

Form No.

Case No.

For Office Use Only PRI

For Office Use Only Pension No.

PWGSC-TPSGC 2460 (09/2009)

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