RCMP-GRC 2069E: Pensionable employment questionnaire

Pensionable employment questionnaire PDF, 1.0MB)

Protected "B" when completed

Privacy notice

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

Plan member's personal information
Preferred language

Under the 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.

1. Release authorization of the member (To be completed by the member)

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.

2. Particulars of employment (Section 2, 3 and 4 to be completed by plan administrator)
1. Was this person subject to your pension fund or plan during his employment?
2. Type of plan:

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.

Service credit for each year.
Year Full-time or percentage part-time Service from  ( YYYYMMDD) Service to  ( YYYYMMDD) Pensionable earnings (post-1989 years) Service credit PA/ PSPA Amount DB component Footnote 1 PA - Amount DC component Footnote 2
3. Particulars of pension benefits upon termination of employment

A. Upon termination of employment, to which of the following benefits was the employee entitled under your pension plan?


   Underwritten by Government Annuities Contract Branch

B. If the benefit was a type described in 3A (a), (b) or (c):

(e) If the payment has been made, how was it paid?


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).

From  ( YYYYMMDD) To  ( YYYYMMDD) Benefit type Service credit Reason benefit remains

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?

  1. Police Officer Service Dates
  2.  (YYYYMMDD)
4. Certification

The information provided in this questionnaire is certified to be correct.

RCMP- GRC 2069E (2014-07-001)

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