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PWGSC-TPSGC 2040: Statutory declaration (Public Service Superannuation Act administration)

Privacy notice

Information provided on this document is necessary by law under the Public Service Superannuation Act. This information is retained under Personal Information Bank Number PWGSC PCE 702. Access to this information will be refused for unauthorized persons/agencies following the provisions of the Privacy Act. Under the Act you have the right to request access to your personal information held by a federal government institution. You can also request corrections if you believe the information contains errors or omissions. Information that you give about another individual is available to that person following the provisions of the Privacy Act.

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PWGSC-TPSGC 2040 - Statutory declaration (Public Service Superannuation Act administration) [PDF - 656 KB]

Protected "B" when completed

Use this form only if there is no person entitled by law to act as a committee or curator for the recipient who is unable to manage or is incapable of managing his or her own affairs. Complete two copies of this form; send the original to the address below and keep the second copy for your records.

If there is a legal committee, please send a certified copy of the court order, or other instrument appointing the committee, to:

Public Works and Government Services Canada, Public Service Pension Centre - Mail Facility
150 Dion Blvd
PO Box 8000
Matane QC G4W 4T6.

,
(Full name of declarant)

(Number and Street)

solemnly declare as follows:


(Full name of recipient)

receives a benefit under the Public Service Superannuation Act.

  1. * Mother, father, sister, brother, spouse, daughter, son, etc.; if not immediate family, give explanation on a separate sheet of paper.
  2. If the proposed payee is an institution, give your position title and the name of the institution.

2. I know the recipient cannot manage his or her own affairs for the reasons stated in the certificate of

marked Exhibit "A" to this declaration.

3. There is no person entitled by law to act as a committee of the recipient, and

4. If the monies payable to the recipient are paid to me, I agree:

  1. to manage the monies for the care of the recipient and his or her dependants during the period he or she cannot manage his or her own affairs;
  2. to indemnify and save harmless the Government of Canada from and against all claims for which it may be liable because of the payments being made to me instead of the recipient; and
  3. to let Public Works and Government Services Canada, Public Service Pension Centre - Mail Facility 150 Dion Blvd, PO Box 8000 Matane QC G4W 4T6, know if:
    1. the recipient becomes able or capable of managing his or her own affairs, or
    2. the recipient dies.

5. Marked Exhibit "B" to this declaration is a certificate from two responsible persons. They recommend that I am a proper person to manage the payments due to the recipient under the Public Service Superannuation Act.

I make this solemn declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.

(City, Town or Village)

(Signature of person authorized to take a Statutory Declaration. (Indicate whether a Justice of the Peace, Notary, Lawyer, Commissioner of Oaths (expiry date must be indicated), etc. and use stamp or seal)

Exhibit "A" - Certificate of medical practitioner

,
(Name of medical practitioner)

(City, Town or Village)

(Full name of recipient)

Exhibit "B" - Certificate of responsible persons

The "Certificate of Responsible Persons" must be completed by two responsible persons not related to either the recipient or the proposed payee and not financially interested in the proposed designation. These persons should not include:

  1. the medical practitioner who has certified incapacity,
  2. the person before whom the statutory declaration was sworn, and
  3. the employees of any institution being proposed as payee.

(Full name of proposed payee)

(Full name of recipient)

who cannot manage his or her own affairs.

PWGSC-TPSGC 2040 (03/2011)

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