Pensionable employment questionnaire PDF, 1.0MB)
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.
This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.
Royal Canadian Mounted Police Superannuation Act a member may choose to count as pensionable service a period of employment with your organization.
If pension records are not held in your office, forward this form to your pension plan administrator.
Period of employment
I hereby authorize for release to the Government of Canada Pension Centre, any information requested by this form regarding the time, duration and pensionable status of my former employment with your organization. I also authorize the release of information held by the pension plan administrator.
3. (a) State the official title of your pension plan
(b) Please indicate if your pension plan is registered under the
Canadian Income Tax Act
4. State the service credit for each year. If additional space is required, attach a separate sheet.
A. Upon termination of employment, to which of the following benefits was the employee entitled under your pension plan?
B. If the benefit was a type described in 3A (a), (b) or (c):
C. If any portion of the benefit remains or will remain to the employee's credit after payment described in 3A(a), (b) or (c), please complete table below and indicate reason (ex. non-transferable, etc).
D. Was any service subject to a pension division as a result of a marriage breakdown?
If yes, please provide the affected period of service
E. Police Officer Service: For the purposes of the
RCMPSA, a police officer is defined as any Canadian citizen, who has graduated from a recognized Canadian police training institution, has acquired Canadian police experience and who has preserved and maintained public safety.
As per the definition stated above, would any service qualify as service as a police officer?
The information provided in this questionnaire is certified to be correct.
GRC 2069E (2014-07-001)