PWGSC-TPSGC 571E - Enrolment Information and Acknowledgment of Plan Membership

Protected B when completed

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

PRI no. Required - 9 digits starting with 0 (Required - 9 digits starting with 0)

Example: 012345678

First name

Pension no. (9 digits)

Date of birth (YYYY-MM-DD)

Preferred language

English

French

Telephone number (8001234567)

Home address

Apartment number

City

Province/Territory

Postal code (A9A9A9)

Country

Personal email address (name@domain)

Work telephone number (8001234567)

Work email address (name@domain) (optional)

Part 2 – Plan membership acknowledgement

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 2196E-TPSGC) 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-year maximum includes pensionable service to your credit under other federal government pension plans (such as the Canadian Armed Forces and Royal Canadian Mounted Police pension plans).

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

Single

Married

Widowed

Divorced

Separated

Common-law

Identify the following if applicable:

Person	First and last name	Date of birth (YYYY-MM-DD)
Married spouse or common-law partner
Child 1 under age 25
Child 2 under age 25
Child 3 under age 25
Child 4 under age 25

Attach a separate sheet if you need more space to write.

Part 4 – Signature and date

Date (YYYY-MM-DD)

Mail or fax your completed form

Government of Canada Pension Centre - Mail Facility
150 Dion Blvd
PO Box 8000
Matane, QC G4W 4T6
Fax: 1-418-566-6298

Questions?

Do 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.

For office use only

Form number

Case number

PRI number

Pension number

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

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