RCMP-GRC 1422E: Deductions from annuity or annual allowance

Deductions from annuity or annual allowance (PDF 724KB)

Protected "B" when completed

Privacy notice

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.

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

Instruction

Carefully read instructions before completing
This form must be completed to authorize deductions from your pension.

To request that no deductions be taken from your annuity, go directly to the Signature of plan member section on page 3.

Plan
  1. Medical Service Plan of British Columbia (See instruction 2)
  2. Medavie Blue Cross
  3. Canada Savings Bonds
  4. Public Service Health Care Plan (PSHCP) (See instruction 3)
  5. United Way (see instruction 4)
  6. Other Deductions (please specify)
Signature of plan member

Please check one of the following boxes:

To be completed by the Government of Canada Pension Centre

Type of entitlement:

Deductions from annuity or annual allowance instructions

  1. This form is required by the Department of Public Works and Government Services Canada to assist plan members who will terminate employment and receive a monthly pension benefit to maintain an orderly flow of legal assignment payments and to minimize the inconvenience which might be caused by a delay in these payments.
    The completed form must be sent to the Public Service Pension Centre. Retain a copy for your records.
  2. Medical Services Plan of British Columbia. For residents of British Columbia, monthly premiums may be deducted from your pension. To enrol under the RCMP Pensioner Group Plan (plan number 5820261) complete the Application for Group enrolment with British Columbia Medical Services Plan (HLTH 167). Attach the signed application with original signature to this form
  3. Public Service Health Care Plan (PSHCP). To apply for Pensioner PSHCP for yourself and any eligible dependants, you must complete the pensioner application from TBS-SCT 006492. Attach the signed application with original signature to this form.
    Public Service Health Care Plan information and the monthly rates are available at: Your Royal Canadian Mounted Police pension and benefits
    Note    : Certain Agencies and Public Service Corporations do not participate in the regular Public Service insurance programs. Former employees of those Agencies or Corporations cannot participate in these programs as pensioners. If you are a member who is currently employed by an organization who does not participate in the Public Service Health Care Plan, please contact your employer for information concerning your eligibility to participate in a health care plan for Retirees
  4. United Way. Complete only if you currently have a United Way deduction. Unless a new pledge form is completed for the new campaign year, this deduction will cease at the end of the current calendar year

RCMP- GRC 1422E (2014-07-001)

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