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 & 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

• Public Service Health Care Plan (PSHCP)
• Public Service Pension Plan
  • Pension Benefits Division
  • Retirement
  • Supplementary Death Benefit
  • Survivor

Public Service Health Care Plan (PSHCP)

006482

Claim Form TBS
Complete this form if you are a member and wish to make a claim for eligible health care expenses from the PSHCP.

006483

Claim Form for Comprehensive Coverage TBS
Complete this form if you are a member and wish to make a claim for eligible health care expenses from the PSHCP.

006492

Public Service Health Care Plan – Pensioner Application TBS (PDF 91 KB)
Complete this form if you wish to apply for coverage under the PSHCP as a pensioner.

Public Service Pension Plan

Pension Benefits Division

2483

Statutory Declaration – In the matter of Provision of Pension Benefits Information under the Pension Benefits Division Act PWGSC (PDF 18.9 KB)
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

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

2486

Application for Division of a Public Service Superannuation Act Pension Benefits in Accordance with the Pension Benefits Division Act PWGSC (PDF 18.4 KB)
Complete this form if you are applying for a division of the pension benefits accumulated during the period of cohabitation.

2488

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 19.5 KB)
Complete this form to request an estimate of the maximum transferable amount allowed for Division.

Retirement

2040

Statutory Declaration PWGSC (PDF 32 KB)
This form is required in cases where the pensioner is unable to manage his/her own affairs.

2265

Pension Information Release PWGSC (PDF 38 KB)
This form is required to verify Québec and Canada Pension disability information. Note: Form is only valid if printed on legal size paper (81/2 X 14)

Supplementary Death Benefit

2196

Naming or Substitution of a Beneficiary PWGSC (PDF 73 KB)
Complete this form if you wish to name or change your beneficiary for your Supplementary Death Benefit.

2223

Supplementary Death Benefit Claim Form PWGSC (PDF 20 KB)
Complete this form if you are the designated beneficiary to claim the Supplementary Death Benefit payment.

Survivor

2002

Declaration of Attendance at an Educational Institute PWGSC (PDF 117 KB)
Complete this form if you are an eligible dependant of a deceased contributor of the Public Service Superannuation Act (PSSA) and are requesting a Student Allowance. Note: Form is only valid if printed on legal size paper (81/2 X 14)

2016

Statutory Declaration for Common Law Relationship PWGSC (PDF 62 KB)
Complete this form if you wish to provide information about your common-law relationship.