RCMP-GRC 2467-1E: Statutory declaration

Statutory declaration PDF, 346KB)

Protected "B" when completed

Royal Canadian Mounted Police Superannuation Act—Supporting statement

In the Matter of Survivor Benefits Under the Royal Canadian Mounted Police Superannuation Act

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.

Statutory declaration form

To Witness:
.
.
And do solemnly swear that:
I am aware of the following breaks in the relationship of the claimant and the plan member during the period from the date indicated in Statement 3 to the date of the plan member's death for the following reasons:
From  ( YYYYMMDD) To  ( YYYYMMDD) Reason (if known)
I make this solemn declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.

Instructions

  1. For the purposes of Statement 5, please include details concerning your knowledge and to what extent the claimant and the plan member shared finances, shared ownership of property and household items, shared domestic responsibilities, participated jointly in social or recreational activities and shared responsibility for children (if applicable), and explain how they each represented their relationship to family, friends, colleagues and to others in the community. Please address the following items or any other relevant details.
    1. the daily personal relationship of the claimant and the plan member and their care of each other
    2. their joint participation in neighbourhood or community activities and with each other's families and how those families behaved toward each of them
    3. the attitude and conduct of the community towards them both as a couple
    4. the financial arrangements between them with respect to household expenses and ownership of property
    5. their attitude and conduct concerning the responsibility for children in their care
  2. Other federal superannuation acts:
    • Canadian Forces Superannuation Act
    • Public Service Superannuation Act
    • Members of Parliament Retiring Allowances Act
    • Diplomatic Service (Special) Superannuation Act
    • Lieutenant Governors Superannuation Act
    • Governor General's Act
    • Judges Act
  3. If there is not enough space on the declaration form to answer a question fully, attach additional pages and in the response to that question on the form, indicate how many pages are attached. Each attached page must be initialed by you and by the person before whom the statement is being sworn

RCMP- GRC 2467-1E (2014-07-001)

Report a problem or mistake on this page
Date modified: