PWGSC-TPSGC 570: Service buyback payment transmittal for plan member on leave without pay

The personal information is collected pursuant to the Department of Public Works and Government Services Act, para. 7(1)(d) and s.13. The personal information will be used by the Receiver General and Pension branch of Public Services and Procurement Canada for the purpose of administrating the Public Service Superannuation Act. 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 for the pension program will be retained for a period of a minimum of 2 years after the last administrative action, and then destroyed. 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.

This form is used by the plan member for the purpose of remitting payments in respect of a period of leave without pay and/or a service buyback. This form provides information necessary for accounting purposes.

Send the completed form to the following address together with your payment:

Public Service Pension Centre - Mail Facility
150 Dion Blvd
P.O. Box 8000
Matane QC G4W 4T6

Cash payments such as personal cheques and money orders must be made payable to the Receiver General for Canada.

If sending a payment in respect of more than one service buyback, indicate the total of the monthly deduction amount for all service buybacks.

If your payment is made through a direct transfer of funds from a Registered Retirement Savings Plan (RRSP), complete and attach the Canada Revenue Agency form T2033 to this form (in lieu of a cheque
or money order).

Note: In Part C of the form T2033 indicate "0288795" for the CRA registration number and "Public Service
Superannuation Account" for the RPP name.

Residents of Ontario and Québec must add the provincial sales tax to the amount of Supplementary Death Benefit (SDB) contributions, 8% for Ontario and 9% for Québec.