Here you will find a collection of forms related to your pension and insurance benefits plans. To use the forms below, you must first print the form, complete it by hand and return it by mail to the following address:

Public Works and Government Services Canada
Public Service Pension Centre - Mail Facility
150 Dion Blvd
PO Box 8000
Matane QC  G4W 4T6

You may also obtain these forms and others by contacting the Public Service Pension Centre.

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Table of Contents

• Dental Care Plan
• Disability Insurance
• Public Service Health Care Plan
• Public Service Management Insurance Plan
• Public Service pension plan
  • Pension Benefits Division
  • Preparing for Retirement
  • Service Buyback
  • Supplementary Death Benefit
  • Survivor
• Forms Available from your Compensation Advisor

Dental Care Plan

Standard Claim Forms

6267

Public Service Dental Care Plan Form TBS
Complete this form if you are making a claim for dental expenses under the Public Service Dental Care Plan.

M6591

Public Service Dental Care Plan - Authorization for Claims Submission and Re-Direction of Payment Great-West Life
Complete this form to authorize someone else to make a claim for dental expenses for your eligible children under the Public Service Dental Care Plan.

Disability Insurance

Standard Claim Forms

330-302

Claim for Disability Insurance – Employee's Statement Policy No. 12500-G TBS
Complete this form if you are applying for disability benefits under the Disability Insurance Plan.

330-304

Claim for Disability Insurance – Employee's Medical
Information and Attending Physician's Statement Policy No. 12500-G TBS
Have your physician complete this form if you are applying for disability benefits under the Disability Insurance Plan.

Public Service Health Care Plan

Standard Claim Forms

6482

Public Service Health Care Plan Form TBS
Complete this form if you are claiming medical expenses under the Public Service Health Care Plan.

Comprehensive Coverage Claim Forms

6483

Out-of-Country Claims Comprehensive Coverage TBS
Complete this form if you are claiming medical out of the country expenses under the Public Service Health Care Plan.

Public Service Management Insurance Plan

Death Benefit

5948, 5949

Public Service Management Insurance Plan Claim for Death Benefit TBS
Complete form 5949 if you are making a claim for death benefit under the Public Service Management Insurance Plan. Only complete form 5948 if the death is accidental.

Long-term Disability Insurance

5945, 5946

Public Service Management Insurance Plan Claim for Long-term Disability Benefit TBS
Complete form 5946 if you are making a claim for long-term disability benefits under the Public Service Management Plan. Have your physician complete form 5945 if you are making a claim for long-term disability benefits under the Public Service Management Insurance Plan.

5954, 5955

Public Service Management Insurance Plan Claim for Accidental Dismemberment Benefit TBS
Complete form 5955 if you are making a claim for accidental dismemberment benefits under the Public Service Management Insurance Plan. Have your physician complete form 5954 if you are claiming accidental dismemberment benefits.

Public Service pension plan

Pension Benefits Division

2483
(PDF, 18.9KB)

Statutory Declaration – In the matter of Provision of Pension Benefits Information under the Pension Benefits Division Act PWGSC (PDF, 18.9KB)
If you are requesting an estimate of the maximum transferable amount allowed for division, complete this form to establish your period of cohabitation (including any interruptions).

2484
(PDF, 95.8KB)

Statutory Declaration – In the matter of an Application for Division of Pension Benefits under the Pension Benefits Division Act PWGSC (PDF, 95.8KB)
Complete this form if you are applying for a pension division and your Court Order or Agreement does not include the cohabitation period.

2486
(PDF, 1.01MB)

Application for Division of a Public Service Superannuation Act Pension Benefits in Accordance with the Pension Benefits Division Act PWGSC (PDF 1.01MB)
Complete this form if you are applying for a division of the pension benefits accumulated during the period of cohabitation.

2488
(PDF, 19.5KB)

Request for Pension Benefits Division Information with respect to a Public Service Superannuation Act Pension in Accordance with the Pension Benefits Division Act PWGSC (PDF, 19.5KB)
Complete this form to request an estimate of the maximum transferable amount allowed for Division.

Preparing for Retirement

Mandatory Forms

2265
(PDF, 140KB)

Pension Information Release PWGSC (PDF, 140KB)
This form is required to verify your entitlement to Canada and Quebec Pension Plan disability and retirement benefits. Note: Form is only valid if provided on legal paper (81/2 x 14)

Optional Forms

040

Request Form – Direct Deposit to the United States PWGSC
Complete this form if you wish to have your pension cheque deposited to your Bank Account in the United States.

2017
(PDF, 481KB)

Election to Continue as a Participant Under the Supplementary Death Benefit Plan PWGSC (PDF, 481KB)
Complete this form if you are entitled to a deferred annuity or an annual allowance payable more than 30 days after retirement and you wish to continue coverage under the Supplementary Death Benefit Plan.

Other Forms

If you wish to increase your tax credit beyond the basic personal amount, please complete the TD1 Personal Tax Credits Return Form as well as the corresponding provincial form below.

TD1 Personal Tax Credits Return

TD1 Personal Tax Credits Return
TD1-WS Worksheet for the Personal Tax Credits Return

Alberta
TD1AB Alberta Personal Tax Credits Return
TD1AB-WS Worksheet for the Alberta Personal Tax Credits Return

British Columbia
TD1BC British Columbia Personal Tax Credits Return
TD1BC-WS Worksheet for the British Columbia Personal Tax Credits Return

Manitoba
TD1MB Manitoba Personal Tax Credits Return
TD1MB-WS Worksheet for the Manitoba Personal Tax Credits Return

New Brunswick
TD1NB New Brunswick Personal Tax Credits Return
TD1NB-WS Worksheet for the New Brunswick Personal Tax Credits Return

Newfoundland and Labrador
TD1NL Newfoundland and Labrador Personal Tax Credits Return
TD1NL-WS Worksheet for the Newfoundland and Labrador Personal Tax Credits Return

Northwest Territories
TD1NT Northwest Territories Personal Tax Credits Return
TD1NT-WS Worksheet for the Northwest Territories Personal Tax Credits Return

Nova Scotia
TD1NS Nova Scotia Personal Tax Credits Return
TD1NS-WS Worksheet for the Nova Scotia Personal Tax Credits Return

Nunavut
TD1NU Nunavut Personal Tax Credits Return
TD1NU-WS Worksheet for the Nunavut Personal Tax Credits Return

Ontario
TD1ON Ontario Personal Tax Credits Return
TD1ON-WS Worksheet for the Ontario Personal Tax Credits Return

Prince Edward Island
TD1PE Prince Edward Island Personal Tax Credits Return
TD1PE-WS Worksheet for the Prince Edward Island Personal Tax Credits Return

Quebec
TP-1015.3-V Source Deductions Return

Saskatchewan
TD1SK Saskatchewan Personal Tax Credits Return
TD1SK-WS Worksheet for the Saskatchewan Personal Tax Credits Return

Yukon
TD1YT Yukon Personal Tax Credits Return
TD1YT-WS Worksheet for the Yukon Personal Tax Credits Return

Service Buyback

2005
(PDF, 552KB)

Election Form for Transfer Value Service PWGSC (PDF, 552KB)
Complete this form if you wish to buy back prior service for which you received a Transfer Value.

2069
(PDF, 154KB)

Pensionable Employment Questionnaire PWGSC (PDF, 154KB)
Have your former employer complete this form if you are buying back prior service outside the Federal Public Service.

2092
(PDF, 329KB)

Election to Surrender Benefits PWGSC PWGSC (PDF, 329KB)
Complete this form if you wish to surrender your benefits under the Canadian Forces or the Royal Canadian Mounted Police and have that service counted as pensionable service under the Public Service pension plan.

3006
(PDF, 178KB)

Election Form for Elective Pensionable Service PWGSC PWGSC (PDF, 178KB)
Complete this form if you wish to buy back prior service and have it counted as pensionable under the Public Service pension plan.

Supplementary Death Benefit

Reduce Benefit

2041-1
(PDF, 275KB)

Election to Reduce Benefit to $10,000 PWGSC (PDF, 275KB)
Complete this form if you are preparing for retirement and you wish to reduce your Supplementary Death Benefit coverage to $10,000.00.

Naming or Substitution of a Beneficiary

2196
(PDF, 409KB)

Naming or substitution of a beneficiary PWGSC (PDF, 409KB)
Complete this form if you wish to name or change your beneficiary under the Supplementary Death Benefit.

Standard Claim Forms

2223
(PDF, 267KB)

Supplementary Death Benefit Claim Form PWGSC (PDF, 267KB)
Complete this form if you are the designated beneficiary to claim the Supplementary Death Benefit payment.

Survivor

Declaration Forms

2010
(PDF, 1.46MB)

Statutory Declaration – In the Matter of the Public Service Superannuation Act PWGSC (PDF, 1.46MB)
Complete this form if you are the guardian of the surviving child of a deceased member and are applying for the children's allowance.

2016

Statutory Declaration for Common Law Relationship PWGSC
Complete this form if you wish to provide information about your common-law relationship.

2467
(PDF, 136KB)

Statutory Declaration – Public Service Superannuation Act – Subsection 25(4) – Claimant's Statement PWGSC (PDF, 136KB)
Complete this form if you are the common-law or same-sex partner and are applying for the survivor pension.

2467-1
(PDF, 119KB)

Statutory Declaration – Public Service Superannuation Act – Subsection 25(4) – Supporting Statement PWGSC (PDF, 119KB)
If you are applying for the survivor pension as a common-law or same-sex partner, have two people who know of your relationship complete this form in support of your survivor pension application.

Forms Available from your Compensation Advisor

Below is a list of additional forms that you may require; however, they are only available from your Compensation Advisor.

Disability Insurance

330-303

Claim for Disability Insurance – Employer's Statement Policy No. 12500-G TBS

Preparing for Retirement

Mandatory Forms

1422

Deductions from Annuity or Annual Allowance PWGSC

2011

Notice of Termination and Option for Benefit PWGSC

Other Forms

2011-1

Reason for Termination and Option for Benefit Air Traffic Controllers (ATC) Operational Service PWGSC

2011-2

Option for Benefit – Operational Service, Correctional Service Canada PWGSC

Public Service Management Insurance Plan

Basic Life Insurance

2028

Public Service Management Insurance Plan PWGSC

2028-5

Public Service Management Insurance Plan – Part-time employee only PWGSC

Change of Name or of Beneficiary

2028-1

Public Service Management Insurance Plan (Change of Name or of Beneficiary) PWGSC

Long-term Disability Insurance

2027

Long-term Disability Insurance – Public Service Management Insurance Plan PWGSC

2027-1

Long-term Disability Insurance – Public Service Management Insurance Plan (Part-time Employee Only) PWGSC

PSMIP Supplementary Life Insurance

2028-7

Public Service Management Insurance Plan – Members Entitled to Government-Paid Coverage PWGSC