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Pension Diversion Regulations (SOR/84-48)

Regulations are current to 2022-06-20 and last amended on 2020-12-23. Previous Versions

SCHEDULE II(Section 14)

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Public Works and ​Governments Services CanadaTravaux publics et Services gouvernementaux Canada

Protected “B” when completed

Protégé « B » une fois rempli

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Application Under Section 35.3 of the Garnishment, Attachment and Pension Diversion Act and Section 14 of the Pension Diversion Regulations

PART 1Plan Member

Please provide the following information concerning the plan member.

1Name (given names, surname) – Nom (prénoms, nom de famille)2Date of birth – Date de naissance
Y– AMD–J
3Most recent known addressPostal code – Code postal4Social Insurance No. (optional)
Dernière adresse connueN° d’assurance sociale (facultatif)
5 Last public service employer – Dernier employeur dans la fonction publique
Department — Agency / Crown corporationBranchLocation
Ministère — Organisme/Société d’ÉtatDirection généraleLieu
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6Please provide any other information that might aid in identifying the plan member.7Date of retirement (if known)
Veuillez fournir tout autre renseignement susceptible d’aider à identifier le participant au régime.Date de la retraite (si elle est connue)
Y –AMD –J
8Superannuation No. (if known)
N° de pension de retraite (s’il est connu)

PART 2Applicant

9Applicant’s name (given names, surname) – Nom du réquérant (prénoms, nom de famille)
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10Is the applicant the person named in the financial support order as being entitled to support?

YesIf yes, go to item 13
Le réquérant est-il la personne nommée dans l’ordonnance de soutien financier comme ayant droit aux aliments?OuiSi oui, passez à l’article 13

NoIf no, complete items 11 and 12
NonSi non, répondez aux articles 11 et 12
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11Relationship to the person named in the financial support order as being entitled to support
Lien avec la personne nommée dans l’ordonnance de soutien financier comme ayant droit aux aliments
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12Person named in the financial support order as being entitled to support (given names, surname), if different from the applicant13Date of birth – Date de naissance
Personne nommée dans l’ordonnance de soutien financier comme ayant droit aux aliments (prénoms, nom de famille) si différente du réquérantY –AMD – J
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14Address to which the information is to be sentPostal code –Code postal15Preferred language – Langue préférée
Adresse à laquelle les renseignements doivent être envoyés

English/Anglais

French/Français
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PART 3Documentation

A copy of the financial support order under which the application is made must be attached.

PART 4Authorization

I request pension benefits information in respect of the plan member named in Part 1 of this application in accordance with the Garnishment, Attachment and Pension Diversion Act and Pension Diversion Regulations. I understand that a notation reflecting that such a request has been made will be placed on the plan member’s personal record once the information is sent to me.

Signature

Date (YYYY/MM/DD)
Date (AAAA-MM-JJ)

Minister of Public Works and Government Services / Ministre des Travaux publics et Services gouvernementaux

Government of Canada Pension Centre – Mail Facility / Centre des pensions du gouvernement du Canada — Service du courrier

150 Dion Boulevard / 150, boulevard Dion

Send the duly completed application to

P.O. Box 8000 / C.P. 8000

Transmettez la demande dûment remplie à l’addresse

Matane, Quebec G4W 4T6 / Matane (Québec) G4W 4T6

PWGSC-TPSGC 2491 (2/97)
 
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