RCMP-GRC 2486E - Application For Division of a Royal Canadian Mounted Police Superannuation Act Pension Benefits in Accordance with the Pension Benefits Division Act

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Protected "B" when completed

Privacy Notice

Provision of the personal information including the social insurance number (SIN) 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 division of pension benefits and CRA/RQ reporting and 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.

Plan Member's Personal Information

(YYYYMMDD)
Preferred Language
A. Current or Former Spouse / Common-Law Partner of Plan Member
B. Applicant
I am applying as the:
Personal representative of the:
C. Supporting Documents
D. Applicant's Signature

I hereby apply for the division of the pension benefits accrued to the plan member named herein under the Royal Canadian Mounted Police Superannuation Act in accordance with the Pension Benefits Division Act.

(YYYYMMDD)

The completed application and supporting documents are to be returned to:

Government of Canada Pension Centre - Mail Facility
150 Dion Boulevard
PO Box 8500
Matane QC G4W 0E2

Note: Every person who knowingly makes a false or misleading representation in any application or other proceeding under the Pension Benefits Division Act is guilty of an offence punishable on summary conviction.

RCMP-GRC 2486E (2014-07-001)