PWGSC-TPSGC 2041-1: Election to reduce benefit to $10,000 - Form A

Privacy notice

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 electing to reduce benefits to $10,000 under the Supplementary Death Benefit Plan, Part II. This personal 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.

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PWGSC-TPSGC 2041-1 - Election to reduce benefit to $10,000 - Form A [PDF - 216 KB]

Protected "B" when completed

Plan member's personal information

Surname

Plan Member's Personal Information PRI

Given Names

Pension Number

Preferred Telephone No.

Date of Birth (YYYYMMDD)

Preferred Language

English French

Home address

Apartment No.

City

Province

Postal Code

Country

Email Address (optional)

Election to reduce benefit

I, ,

hereby irrevocably elect to reduce my benefit to $10,000 under the Supplementary Death Benefit Plan, Part II of the Public Service Superannuation Act.

I understand that the contribution required until April 1^st or October 1^st, immediately following my sixty-fifth birthday will be one dollar and fifty cents ($1.50) per month and that no contribution will be required after that time. I also understand that this election will take effect on the first of the month following its receipt by Public Service Pension Centre.

Witness

Witness Signature

Witness Date (Y-M-D)

Member

Member Signature

Member Date (Y-M-D)

This form is to be forwarded to:

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

For office use only

Form No.

Case No.

For Office Use Only PRI

For Office Use Only Pension No.

PWGSC-TPSGC 2041-1 (09/2009)

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From:

Public Services and Procurement Canada

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2025-08-15

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