Surrender of Benefits

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PWGSC-TPSGC 2092 - Surrender of Benefits

Provision of the information requested on this document is voluntary. This information is being collected in accordance with the Public Service Superannuation Act (PSSA) for the purpose of surrendering benefits under the Canadian Forces Superannuation Act (CFSA) or the Royal Canadian Mounted Police Superannuation Act (RCMPSA). This information will be stored in Personal Information Bank Number PWGSC PCE 702 and will be protected, used and disclosed in accordance with the Privacy Act. Under this act, employees have the right to request access to their personal information and to request corrections should they believe the information contains errors or omissions. Personal information provided about another individual may be accessible to that person under the Privacy Act. The records will be retained by the department for two years following the last administrative action, and then will be destroyed.

This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.

Plan Member's Personal Information

Surname

PRI

Given Names

Plan Member's Personal Information Pension No.

Preferred Telephone No.

Date of Birth (YYYYMMDD)

Preferred Language

English French

Home address

Apartment No.

City

Province

Postal Code

Country

Email Address (optional)

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.

NOTE: Pay Office (PO), Paylist (PL), and Department (Dept.) can be found on the upper left hand corner of your pay stub.

CF or RCMP Pension No.

Dept

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

Pension Services Directorate
Public Works and Government Services Canada
1451 Coldrey Avenue
Ottawa ON K1A 0S5

Attention: Specialized Services Division - Canadian Forces

Public Works and Government Services Canada – RCMP
Government of Canada Pension Centre – Mail Facility
150 Dion Boulevard
PO Box 8500
Matane QC G4W 0E2

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:

Canadian Forces Superannuation Act / Defence Services Pension Continuation Act

Royal Canadian Mounted Police Superannuation Act / Royal Canadian Mounted Police Pension Continuation Act

2. I further choose to pay for the period of service that was countable for pension purposes under the above Act (s).

In a lump-sum, by transfer to the Public Service Pension Fund of the contributions to my credit under the applicable act (which transfer I hereby authorize):

In a lump-sum, by cheque or money order (enclosed), payable to the Receiver General for Canada, in the sum of: sum of

In monthly instalments to be deducted from my salary in accordance with the provisions of the Public Service Superannuation Act.:

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:

by lump-sum of

(enclosed is a cheque or money order payable to the Receiver General for Canada), or

by monthly instalments over years to be deducted from my salary in accordance with the provisions of the Public Service Superannuation Act.

Signature

Date (Y-M-D)

NOTE TO CFSA/RCMPSA: Original to be forwarded to Public Service Pension Centre - Mail Facility by the CFSA/RCMPSA plan administrator

For Office Use Only

Form No.

Case No.

For Office Use Only PRI

For Office Use Only Pension No.

PWGSC-TPSGC 2092 (09/2009)