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
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
  • Retirement/Termination of Employment
  • Service Buyback
  • Supplementary Death Benefit
  • Survivor
• Forms Available from your Compensation Advisor

Dental Care Plan

Standard Claim Forms

• Form 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.
• Form 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

• Form 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.
• Form 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

• Form 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

• Form 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

• Form 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

• Form 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.
• Form 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

• Form 2483 - 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).
• Form 2484 - 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.
• Form 2486 - 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.
• Form 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, 19.5KB)
  Complete this form to request an estimate of the maximum transferable amount allowed for Division.

Retirement/Termination of Employment

• Form 1422 - Deductions from Annuity or Annual Allowance PWGSC PDF, 259KB
  This form is used to authorize deductions from a monthly pension benefit payable on termination.
• Form 2265 - Pension Information Release PWGSC (PDF, 140KB)
  This form is required to verify your entitlement to Canada and Quebec Pension Plan disability and retirement benefits.
• Form 2347-18 - Certification of Lock-in Purposes of the Public Service Superannuation Act or the Pension Benefit Division Act PWGSC (PDF, 225KB)
  This form is used to certify lock-in of pension funds for a Transfer Value payment. Please complete the Plan Member's Personal Information section and ask your financial institution to complete the Certification section.
• Form T2151 - Direct Transfer of a Single Amount Under Section 147(19) or Section 147.3 T2151 T2151
  This form is used to transfer out pension funds.
• Form 040 - Request Form – Direct Deposit to the United States PWGSC (PDF, 179KB)
  Complete this form if you wish to have your pension cheque deposited to your Bank Account in the United States.
• Form 2017 - Election to Continue as a Participant Under the Supplementary Death Benefit Plan PWGSC (PDF, 220KB)
  Complete this form if you wish to continue coverage under the Supplementary Death Benefit Plan at commercial rates.
• Form 006492 - Public Service Health Care Plan Pensioner Application  TBS 006492 (PDF, 91.4KB)
  Complete this form if you are eligible to apply for this coverage.

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 (www)

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

• Form 2005 - Service Buyback 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.
• Form 2069 - 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.
• Form 2092 - Surrender of 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.
• Form 3006 - Service Buyback form 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

• Form 2041-1 - 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

• Form 2196 - 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

• Form 2223 - Supplementary Death Benefit Plan – Beneficiary Information PWGSC (PDF, 267KB)
  Complete this form if you are the designated beneficiary to claim the Supplementary Death Benefit payment.

Survivor

Declaration Forms

• Form 2010 - 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 plan member and are applying for the children's allowance.
• Form 2016 - Statutory Declaration for Common Law Relationship PWGSC (PDF, KB)
  Complete this form if you wish to provide information about your common-law relationship.
• Form 2467 - 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.
• Form 2467-1 - Statutory Declaration – Public Service Superannuation Act – Subsection 25(4) – Supporting Statement PWGSC (PDF, 119KB)
  Have two persons who know of your common-law relationship each complete this form in support of your claim for a survivor pension as a common-law partner of a deceased plan member.

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

• Form 330-303 - Claim for Disability Insurance – Employer's Statement Policy No. 12500-G TBS

Public Service Management Insurance Plan

Basic Life Insurance

• Form 2028 - Public Service Management Insurance Plan PWGSC
• Form 2028-5 - Public Service Management Insurance Plan Part-time employee only PWGSC

Change of Name or of Beneficiary

• Form 2028-1 - Public Service Management Insurance Plan (Change of Name or of Beneficiary) PWGSC

Long-term Disability Insurance

• Form 2027 - Long-term Disability Insurance – Public Service Management Insurance Plan PWGSC
• Form 2027-1 - Long-term Disability Insurance – Public Service Management Insurance Plan (Part-time Employee Only) PWGSC

PSMIP Supplementary Life Insurance

• Form 2028-7 - Public Service Management Insurance Plan – Members Entitled to Government-Paid Coverage PWGSC

Forms Available from the Public Service Pension Centre

Below is a list of additional forms that you may require; however, they are only available from the Public Service Pension Centre.

• Form 2011E-PF - Pension Benefit Options Statement PWGSC
  This form is used to indicate your pension option.
• Form 439E - Pensioners' Dental Services PWGSC