Statutory declaration PDF, 208KB)
Protected "B" when completed
Provision of the personal information is required 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 Royal Canadian Mounted Police Superannuation Act (RCMPSA) and the Royal Canadian Mounted Police Pension Continuation Act (RCMPPCA). Refusal to provide the personal information, or the provision of incorrect information may result in loss of benefits and/or delays in processing incorrect pension estimates, benefits, or statements. Personal information is protected, and only used and disclosed in accordance with the Privacy Act and as described in Personal Information Bank PWGSC PCU 702 – Federal Pension Administration. Under the Act, individuals have a right of access to their personal information and request correction, if erroneous or incomplete.
Do solemnly declare that:
I have been living in a common-law relationship with
and that should there be a change in this status, I will notify the Government of Canada Pension Centre immediately. And, I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.
Declared before me:
my commission expires on
GRC 2016E (2013-06-001)