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
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)

• Claim Form (www)
  Complete this form if you are a member and wish to make a claim for eligible health care expenses from the PSHCP.
• Claim Form (www) for Comprehensive Coverage
  Complete this form if you are a member and wish to make a claim for eligible health care expenses from the PSHCP.
• Form 006492 - Public Service Health Care Plan – Pensioner Application (www) TBS (PDF, 91KB)
  Complete this form if you wish to apply for coverage under the PSHCP as a pensioner.

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, 18.4KB)
  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

• Form 2040 - Statutory Declaration PWGSC (PDF, 32KB)
  This form is required in cases where the pensioner is unable to manage his/her own affairs.
• Form 2265 - Pension Information Release PWGSC (PDF, 38KB)
  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

• Form 2196 - Naming or Substitution of a Beneficiary PWGSC (PDF, 73KB)
  Complete this form if you wish to name or change your beneficiary for your Supplementary Death Benefit.
• Form 2223 - Supplementary Death Benefit Claim Form PWGSC (PDF, 20KB)
  Complete this form if you are the designated beneficiary to claim the Supplementary Death Benefit payment.

Survivor

• Form 2002 - Declaration of Attendance at an Educational Institute PWGSC (PDF, 117KB)
  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)
• Form 2016 - Statutory Declaration for Common Law Relationship PWGSC (PDF, 62KB)
  Complete this form if you wish to provide information about your common-law relationship.