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PWGSC-TPSGC 2092: Surrender of benefits

Privacy notice

The personal information is collected pursuant to the Department of Public Works and Government Services Act, para. 7(1)(d) and s.13 and will be used for the purpose of administrating the Public Service Superannuation Act (PSSA). 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 Act, you have the right to access and correct your personal information, if erroneous or incomplete. The personal information provided will be retained for a minimum of two 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 of Canada.

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PWGSC-TPSGC 2092 - Surrender of benefits [PDF - 535 KB]

Protected "B" when completed

Plan member's personal information

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Payable under the Canadian Forces Superannuation Act (CFSA) or the Royal Canadian Mounted Police Superannuation Act (RCMPSA).

Note

  • To be completed by recipients of monthly pensions or by persons who have not received or are not entitled to receive a return of CFSA or RCMPSA contributions.

When completed, retain a copy and forward the original to:

Government of Canada Pension Centre – CAF
Mail Facility
150 Dion Boulevard
PO Box 9500
Matane QC  G4W 0H3

Attention: Canadian Armed Forces
OR

Government of Canada Pension Centre – RCMP
Mail Facility
150 Dion Boulevard
PO Box 8500
Matane QC  G4W 0H3

Attention: Royal Canadian Mounted Police
1. I hereby choose, pursuant to Subsection 39(6) of the Public Service Superannuation Act, to surrender the annuity, annual allowance or pension to which I am entitled under the:
2. I further choose to pay for the period of service that was countable for pension purposes under the above Act(s).
3. I further choose to pay the amount required (if applicable) by subsection 39(7) of the Public Service Superannuation Act as pension repayment, in the following manner:
$
(enclosed is a cheque or money order payable to the Receiver General for Canada), or
years to be deducted from my salary in accordance with the provisions of the Public Service Superannuation Act.

Signature

For office use only

PWGSC-TPSGC 2092 (12/2021)

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