PWGSC-TPSGC 2488: Request for pension benefits division information (for estimate purposes) with respect to a Public Service Superannuation Act pension in accordance with the Pension Benefits Division Act

Privacy notice

The personal information is collected on a voluntary basis according 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) to document an application for the division of pension benefits under the Pension Benefits Division Act (PBDA). The personal information is described in the Personal Information Bank PWGSC PCU 702 – Federal Pension Administration, and Pay and Benefit – PSE 904. 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 2 years after the last administrative action, and then destroyed. If you need 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’re 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 want to contact the Office of the Privacy Commissioner of Canada.

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Instructions for fillable PDF forms

Member's PRI or pension number
(The first digit has to be a zero) (Example: 0XX-XXX-XXX)

A. Applicant's information

Last name

First name

I'm applying as the

plan member

current or former married spouse of the plan member

current or former common-law partner of the plan member

I am applying as the personal representative of the above (check appropriate circle above)

B. Send the requested pension benefits division information to this address

Name

Post office box or civic (street) address

City/Town

Province/Territory

Country

Postal code

The above is my current mailing address:

Yes

No

C. Plan member's information

Last name

First name

Date of birth (YYYY-MM-DD)

Telephone number

Member’s PRI or pension number
(The first digit has to be a zero) (Example: 0XX-XXX-XXX)

Employment end date (YYYY-MM-DD)

Not applicable

D. Other information

The person who would be receiving the division amount from the plan member’s pension benefits is (or was) employed with the:

Federal Public Service (FPS)

Royal Canadian Mounted Police (RCMP)

Canadian Armed Forces (CAF)

Not applicable

Their identification number with the above employer is:

E. Confirm beneficiary status for Supplementary Death Benefit (only if stipulated in an attached court order or written agreement)

I hereby request confirmation as to whether the person named in the attached document is the named beneficiary of the plan member's Supplementary Death Benefit under the Public Service Superannuation Act (PSSA). In support of this request, I have attached a certified true copy of a court order or written agreement stating that I am to be named the beneficiary, or that I am entitled to this confirmation.

Signature

Date (YYYY-MM-DD)

F. Enclose these supporting documents with your request (as applicable)

Supporting documents

Copy of the court order or written agreement providing for the division of the plan member's PSSA pension benefits.

If in effect, an original or certified true copy of the document that authorizes a personal representative to act on behalf of: the plan member, the current or former married spouse, or the current or former common-law partner. This document must be mailed to the address shown in section H (a faxed copy is not acceptable).

Statutory Declaration (PWGSC-TPSGC 2483) form outlining period(s) of cohabitation and any breaks therein (if applicable).

G. Applicant's signature

I hereby request pension benefits division information in respect of the plan member named in Section C of this request, in accordance with the Pension Benefits Division Act (PBDA).

If I am not the plan member, I understand that a note regarding this request will be added to the plan member's personal records once the information is sent to me.

I would like to receive the requested information in:

English

French

Signature

Date (YYYY-MM-DD)

Telephone number

H. How to submit your request for pension benefit division information

Ensure you write the plan member’s service number (PRI) or pension number in the top right-hand corner of each page submitted.

Mail or fax this completed Request for Pension Benefit Division Information (for estimate purposes) [PWGSC-TPSGC 2488E] form and any supporting documents to:

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

Fax: 1‑418‑566‑6298

Important: The original or certified true copy of a personal representative document must be mailed, not faxed.

Note: Every person who knowingly makes a false or misleading representation in any application or other proceeding under the PBDA is guilty of an offence punishable on summary conviction.

PWGSC-TPSGC 2488E (2023-09-20)

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PWGSC-TPSGC 2488: Request for pension benefits division information (for estimate purposes) with respect to a Public Service Superannuation Act pension in accordance with the Pension Benefits Division Act

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