RCMP-GRC 2488E - Request for Pension Benefits Division information with respect to the Royal Canadian Mounted Police Superannuation Act Pension in accordance with the Pension Benefits Division Act

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Protected "B" when completed

Privacy Notice

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.

Form RCMP-GRC 2488E

A. Applicant
I'm applying as the:
Personal representative of the:
C. Plan Member
D. Supporting Documents
E. Applicant's Signature - I hereby request pension benefits division information, in respect of the plan member named in Section (C) of this request, in accordance with the PBDA. I understand that a notation reflecting that such a request has been made will be placed on the plan member's personal records once the information is sent to me.

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

RCMP-GRC 2488E (2014-07-001)