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Forms



Notes:

  1. The forms listed below are available in an Adobe Portable Document Format (PDF). To view and print these documents, you need to have Adobe Reader installed on your system. If the PDF document is not accessible to you, please contact us for assistance.
  2. Click on the form title or form number to open the form. You can fill-in the form on your screen and print it, or use the "disk" icon on the Reader toolbar to save a blank copy of the form to your computer. Filled-in forms cannot be saved. To print the form, use the "printer" icon on the Reader toolbar. For form sizes larger than 8.5 x 11 inches, check the "Fit to Page" box in the print window. More detailed instructions are available here.
  3. Fillable forms are marked with an asterisk - * .
  4. Please verify that the form has printed correctly before submitting it as an incompletely or improperly printed form may not be considered a legal document and will not be processed.

Other Forms:


Alphabetical Listing of Forms
    A B C D E F G H I J K L M N O P Q R S T U V W X Y Z  
Form Name
Form No.
A To Top
Accounts Reconciliation
(April 1996)(PDF 10k )
8240-1
Affidavit
(April 1998)( 11k )
540
Application for Certification of a Provisional Past Service Pension Adjustment
(November 2004)( 116k )
2468
Application for Division of a Public Service Superannuation Act Pension in Accordance with the Pension Benefits Division Act
(September 2005)( 1.0M )
2486 *
Application for Division of Members of Parliament Retiring Allowances
(January 2004) ( 161k )
2485
Application for the Refund of PSAC Dues
(March 2006) ( 271k )
2595 *
Arrears of Payment Calculation
(August 2005)( 997k )
2068 *
C To Top
Call Back Control Form
(March 2005)( 389k )
2432 *
Canadian Forces/RCMP Estimate of Cost
(August 2004)( 450k )
2347-14 *
Cash Receipts Register
(May 1995)( 9k )
8638
Central Accounting Journal Voucher
(February 2005)( 134k )
1849
Certificate of Entitlement
(May 2005)( 404k )
2232 *
Certification and Reconciliation of Superannuation Contributions
(January 2005)( 451k )
51 *
Certification Notice - Pension Support System
(December 2005) ( 602k )
2386 *
Certification of Leave Without Pay (for prior contributory service)
(July 2005)( 558k )
2123 *
Certification of Lock-in for Purposes of the Public Service Superannuation Act or the Pension Benefits Division Act
(December 2004)( 309k )
2347-18 *
Certification of Lock-In for Purposes of the Members of Parliament Retiring Allowance Act or the Pension Benefits Division Act
(January 2004) ( 148k )
2347-19
Certification of Operational Service - Correctional Service of Canada
(September 2005)( 287k )
2471 *
Certification of Waiver of Reduction of Annual Allowance (To certify the eligibility of employees for whom Treasury Board is not the employer)
(September 1999)( 12k )
2429-1
Certification of Waiver of Reduction of Annual Allowance (To certify the eligibility of employees for whom Treasury Board is the employer)
(March 2005)( 272k )
2429 *
CFSA/RCMPSA Report of Pensionable Service
(March 2005)( 664k )
2073 *
Cheque Issue List Summary
(June 1996)( 11k )
7456
Client Inquiry - Survivors Case Checklist
(November 2004)( 338k )
2437 *
Common Architecture Security Request
(November 2005)( 416k )
8882-4 *
Common-Law Partner Declaration - Isolated Posts and Government Housing Directive (IPGHD)
(March 2004)( 150k )
7631-1
Compensation Client Address
(October 2001)( 145k )
2719 *
Confidential Questionnaire - Employee Group Insurance, Declaration of Personal Insurability
(December 1994)( 13k )
2229
Contributor Identification Card
(October 2003) ( 70k )
2439-4
Contribution Remittance for Period of Leave Without Pay (Public Service Health Care Plan - PSHCP)
(May 2005)( 335k )
2278 *
Contributor System - Elective Service Input Form (Election)
(August 2005)( 134k )
2242-1 *
Contributor System - Correction Request
(July 2006) ( 700k )
110 *
Contributor System - Elective Service Input Form (Estimate)
(August 2005)( 107k )
2242c *
Contributor System - Public Service Corporations Annual Pro Forma
(October 1997)( 37k )
2343
Contributor System Control File Update Messages File
(October 2004)( 264k )
2285 *
Contributor System - Snapshot Request
(January 2005)( 34k )
2280
Contributor System - TOS - Screening
(September 2003)( 407k )
2276 *
Control Notice
(April 2004)( 65k )
2287
Correction Form - Personnel - Pay Data
(June 1998) ( 12k )
2551
D To Top
Daily Cheque Listing
(April 1999)( 8k )
2364
Declaration of Attendance at an Educational Institute
(October 2004)( 487k )
2002 *
Details of Transfer under a Reciprocal Agreement
(August 2005)( 96k )
2077 *
Deductions from Annuity or Annual Allowance
(November 2005)( 757k )
1422 *
Default Notice
(January 2004)( 97k )
1871
Description du fichier de données des relevés
(Available in French only)
(January 2006)( 126k )
463-05 *
Determination of Eligible Survivors - Deceased Contributor with Two or More Years of Pensionable Service
(November 2004)( 556k )
2008-1 *
Determination of Payee and Amount of Supplementary Death Benefit Payment
(May 2004)( 362k )
2014 *
Determination of Payee for Return of Contributions - Deceased Contributor with Less than Two Years Pensionable Service
(December 2004)( 468k )
2008 *
Direct Deposit - Electronic Deposit of Your Monthly Pension Benefits
(December 2003) ( 119k )
2430
Direct Deposit - Intercept Request - Pension
(March 2005)( 309k )
8432-1 *
Direct Deposit - Intercept or Recall Request - Pay
(May 2005)( 379k )
8432-2 *
Direct Deposit - Enrolment Request
[Public Service Pay / RCMP Pay]
(November 2005) ( 525k )
8437 *
Disability Insurance
(February 1999)( 175k )
2026 *
Disability Insurance - Part-time Employee Only
(October 1999)( 10k )
2026-1
Disposal of Dormant Files Under the Public Service Superannuation Act Administration
(April 2002) ( 7k )
2090-1
E To Top
Election for Spousal Benefit Coverage and a Reduced Pension Entitlement for a Marriage After Retirement
(March 2005)( 319k )
2477 *
Election Form for Elective Pensionable Service
(August 2005)( 462k )
2006 *
Election Form for Transfer Value Service
(April 2005) ( 552k )
2005 *
Election Not to Count Leave Without Pay as Pensionable Service
(November 2004)( 128k )
2480
Election to Become a Contributor to the Public Service Pension Plan
(October 2004)( 284k )
2478 *
Election to Continue as Participant Under Supplementary Death Benefit (SDB) Plan
(February 2005)( 482k )
2017 *
Election to Continue to Pay Extra Contributions for all Additional Years of Non-Operational Service
(March 2000)( 14k )
2469
Election To Reduce Benefit to $10,000
(August 2004)( 275k )
2041-1 *
Election to Surrender Benefits
(June 2004)( 329k )
2092 *
Elective Pensionable Service
(July 2004)( 155k )
107 *
Elective Pensionable Service Record for Operational Services
(March 2000)( 221k )
2001-1 *
Elective Service Notice
(December 2001)( 516k )
2097 *
Eligibility to Contribute
(December 2004)( 416k )
4170 *
Employment or Termination Advice
(June 2004)( 90k )
2120
Estimate of Cost for Elective Pensionable Service
(December 2005)( 983k )
2057 *
Estimate Request and Information Release Authorization for Reciprocal Transfer Agreement Purposes
(August 2004)( 330k )
2472 *
Evidence of Medical Examination
(August 2005)( 590k )
2081 *
F To Top
Form 1 - Election For Prior Sessions Members of Parliament Retiring Allowances Act
(April 2006)( 216k )
380 *
Form 3 - Election Under Subsection 9 (2), Members of Parliament Retiring Allowances Act (November 2005)( 407k ) 435 *
Form 5 - Election to Contribute on Additional Remuneration Received During Prior Sessions (May 2006) ( 480k ) 426 *
Form Letter - Acknowledgement of Receipt of Your Request
(August 2005)( 26k )
2015
Form Letter - Acknowledgment of Retirement
(May 2006) (declared obsolete)
2348
Form Letter - Authorization for Recoveries of Debts due to the Crown
(January 2000)( 167k )
2074 *
Form Letter - Beneficiary Card Invalid
(March 2006)( 168k )
2355 *
Form Letter - Claim for Disability Insurance
(December 2005) ( 466k )
2203 *
Form Letter - Claim for Long-term Disability Insurance
(August 2005)( 39k )
2203-1 *
Form Letter - Contract Employment
(February 2004) ( 109k )
2347-3
Form Letter - Designation of Beneficiary Card
(June 2004)( 129k )
2355-1
Form Letter - DFT, Change of Bank Account Number
(July 2004) ( 100k )
4033
Form Letter - Direct Deposit
(May 2005)( 454k )
2410 *
Form Letter - Disability Insurance Application
(August 2005)( 409k )
2204 *
Form Letter - Disability Insurance Claim
(July 2006)( 667k )
2188 *
Form Letter - Estimate
(June 2004)( 131k )
2347-4
Form Letter - Estimate Cost of Pensionable Employment
(July 2004)( 113k )
2347-5
Form Letter - Invalid Naming or Substitution of Beneficiary
(November 2004) (declared obsolete)
2355-4
Form Letter - Life Insurance
(June 2005) ( 379k )
2380 *
Form Letter - Long-term Disability Insurance
(December 2003) ( 104k )
2380-1
Form Letter - Long Term Disability Insurance Claim
(September 2005)( 542k )
2207 *
Form Letter - Long Term Disability Insurance Claim
(April 2006)( 626k )
2188-1 *
Form Letter - Locating of Pension Cheques
(August 2004) ( 108k )
2037
Form Letter - Medical Examination
(February 2004) ( 125k )
2347-10
Form Letter - Naming or Substitution of a Beneficiary
(August 2004)( 87k )
2355-3
Form Letter - Option After Initial Year
(October 2004)( 303k )
2347-11 *
Form Letter - Option Within Initial Year
(February 2004)( 131k )
2347-12
Form Letter - Outstanding Cheque
(June 2005)( 354k )
2388 *
Form Letter - Pensionable Employment
(June 2004)( 121k )
2268-1
Form Letter - Pensionable Employment With
(February 2004) ( 126k )
2347-2
Form Letter - PSMIP - Assessment of Applications More Than One Year Old
(March 2006) ( 84k )
2395
Form Letter - Request for Screening Documents
(February 2004) ( 111k )
2347
Form Letter - Requesting Additional Information to Positively Identify a Person (contributor)
(May 2004)( 129k )
2093
Form Letter - Requesting Additional Information to Positively Identify a Person (contributor)
(July 2004)( 129k )
2093-1
G To Top
General Change Form - Contributor System
(February 2000)( 10k )
2277
General Change Form - Contributor System (Multiple Entry)
(October 2004)( 121k )
2277-1
I To Top
Information Request - Canada Pension Plan/Quebec Pension Plan
(May 2005) ( 389k )
2302 *
Interpretation of Superannuation Medical Examination
(August 2004)( 517k )
2012 *
Isolated Posts and Government Housing
(October 2003)( 103k )
7631
L To Top
Long Term Disability Insurance - Public Service Management Insurance Plan
(December 2002)( 65k )
2027
Long Term Disability Insurance - Public Service Management Insurance Plan (Part-time Employee Only)
(December 1998)( 13k )
2027-1
M To Top
Mainframe User ID Security Request
(November 2005)( 718k )
5136 *
Members of Parliament Retiring Allowance Act
(December 2004)( 108k )
4175
Miscellaneous Deductions - Code 64
(December 2004)( 337k )
1872 *
Monthly Remittance of Superannuation Contributions (Public Service Corporation)
(July 2000)( 31k )
2292
N To Top
Naming or Substitution of a Beneficiary
(April 2006)( 654k )
2196 *
Notice
(August 2004) ( 90k )
2270
Notice of 35 Years of Pensionable Service
(September 2006)( 167k )
2019 *
Notice of Cancellation - Public Service Health Care Plan (PSHCP)
(July 2004)( 115k )
2397
Notice of Election to Repay Pension of Canadian Forces, RCMP or Members of Parliament
(August 2002)( 224k )
2221 *
Notice of Termination and Option for Benefit
(November 2004)( 457k )
4168 *
Notice of Termination and Option for Benefit - Employees with Two or More Years of Pensionable Service
(March 2006)( 423k )
2011 *
Notice of Termination and Option for Benefit - Employees with Less than Two Years of Pensionable Service
(March 2006)( 2.2M )
2011-3 *
Notification of Contributory Status
(July 2004) ( 101k )
2018
O To Top
Option for Benefit - Operational Service, Correctional Service Canada
(April 2006)( 184k )
2011-2 *
P To Top
Payroll Transfer Journal Voucher
(July 2006)( 319k )
4023 *
Pay System Problem Report - Observation
(December 1999)( 12k )
2579
PBDA Information Request Worksheet
(June 2004)( 160k )
2055
PBDA Information Request Worksheet - Public Service Corporations/Operational Service
(July 2000)( 15k )
2055-1
Pension Adjustment Reversal (PAR)
(February 2002)( 22k )
61
Pension Adjustment Reversal (PAR)
(January 2004)( 110k )
61-03
Pension Benefits Division - Certification of Leave Without Pay
(May 2006)( 446k )
2493 *
Pension Deductions (Members of Parliament)
(October 2004)( 27k )
4142
Pension Information Release
(May 2006)( 431k )
2265 *
Pensionable Employment Questionnaire
(August 2006)( 154k )
2069 *
Pensioners' Dental Services Plan (PDSP) Form - April 1, 2006
Pensioners Entitled to the Veterans Affairs Canada (VAC) Dental Services Program
(April 2006 ) ( 384k )
437 *
Pensioners' Dental Services Plan (PDSP) Form - April 1, 2006 (April 2006 ) ( 290k ) 439 *
Personal Documentation Certification Form
(June 2006)( 304k )
2004 *
Personal - Pay Input and Time Summary Form
(October 1997)( 33k )
2549
Personnel - Pay Input Form
(March 2005)( 441k )
2517-1 *
Personnel - Pay Input Transmittal and Batch Control Form
(October 2000)( 18k )
2546
Post Age 65 Election for Elective Pensionable Service - Annuitant
(March 2000)( 20k )
2473
Post Age 65 Election for Elective Pensionable Service - Employee
(August 1998)( 51k )
2473-1
Post-Retirement Life Insurance Plan
(February 2005)( 532k )
2451 *
Post-Retirement Life Insurance Plan - Certificate of Insurance Members Entitled to Employer-Paid Coverage
(August 2005)( 33k )
2451-2 *
Production Control File Location System
(May 2005)( 21k )
2219-2
Production Control Requisition
(November 2004)( 166k )
4002 *
Proof of Contributor Effective Date
(November 2004) ( 105k )
2459
PSMIP Certificate of Insurance
(June 2005)( 47k )
2029*
PSMIP Certificate of Insurance - Members Entitled to Employer-Paid Coverage
(June 2005)( 34k )
2029-1 *
PSSA Refund (Cash)
(September 1999)( 135k )
7011 *
Public Service Health Care Plan (PSHCP) Application for Designation of Additional Dependant for Comprehensive Coverage
(June 2006)( 193k )
2028-8 *
Public Service Management Insurance Plan
(December 2002) ( 70k )
2028
Public Service Management Insurance Plan (Change of Name or of Beneficiary)
(November 2002)( 317k )
2028-1 *
Public Service Management Insurance Plan - Declaration of Health 2028-2
Public Service Management Insurance Plan - Members Entitled to Government-Paid Coverage
(September 1995)( 20k )
2028-7
Public Service Management Insurance Plan - Part-time employee only
(March 2000)( 12k )
2028-5
Public Service Management Insurance Plan
Post-Retirement Life Insurance - Certificate of Insurance
Judges Plan

(August 2005)( 29k )
398
Public Service Management Insurance Plan (PSMIP) - Certificate of Insurance Judges Plan
(August 2005)( 74k )
400 *
Public Service Superannuation Act - Screening Form for Public Service Corporations
(January 2005)( 469k )
2013 *
Public Service Superannuation Act Administration - Elective Non-Contributory Pensionable Service Record
(February 2005)( 533k )
2001 *
Q To Top
R To Top
Reason for Termination and Option for Benefit Air Traffic Controllers (ATC) Operational Service
(May 2004)( 345k )
2011-1 *
Regional Pay System - Pay Office Input Form
(August 1998)( 13k )
7340
Regional Pay System - Personnel-Pay Input Form
(August 1998)( 15k )
7340-1
Reject Control - EDP Support
(February 2004)( 71k )
2402
Release Authorization
(August 2004)( 271k )
2268 *
Relevé 1 (1998) - Employment Income and Miscellaneous Income
(October 2001)( 73k )
345
Relevé 1 (2001) Employment Income and Miscellaneous Income
(December 2001) ( 67k )
345-01
Relevé 1 (2002) Employment Income and Miscellaneous Income
(January 2003) ( 70k )
345-02
Relevé 1 (2003) Employment Income and Miscellaneous Income
(January 2004) ( 338k )
345-03
Relevé 1 (2004) Employment Income and Miscellaneous Income
(January 2005) ( 121k )
345-04
Relevé 1 (2005) Employment Income and Miscellaneous Income
(May 2006) ( 168k )
345-05 *
Relevé 1 (2006) Employment Income and Miscellaneous Income
(May 2006) ( 169k )
345-06 *
Relevé 2 (2001) - Retirement Income and Annuities
(December 2001)( 64k )
346-01
Relevé 2 (2002) - Retirement Income and Annuities
(January 2003)( 73k )
346-02
Relevé 2 (2003) - Retirement Income and Annuities
(January 2004)( 343k )
346-03
Relevé 2 (2004) - Retirement Income and Annuities
(January 2005)( 113k )
346-04
Relevé 2 (2005) - Retirement Income and Annuities
(January 2006)( 155k )
346-05 *
Relevé 3 (2001) - Investment Income
(December 2001)( 73k )
391-01
Relevé 3 (2002) - Investment Income
(January 2003) ( 79k )
391-02
Relevé 3 (2003) - Investment Income
(January 2004) ( 338k )
391-03
Relevé 3 (2004) - Investment Income
(January 2005) ( 347k )
391-04
Relevé 3 (2005) - Investment Income
(January 2006) ( 132k )
391-05 *
Remittance of Dental Care Plan (DCP) Contributions For a Period of Leave Without Pay
(June 2004)( 355k )
2278-1 *
Repayment of Canadian Forces or RCMP Pension
(July 2005)( 574k )
7752 *
Request for documents
(December 2001)( 50k )
2075-1
Request for Estimate - Transfer Value
(December 2004)( 359k )
2031 *
Request for Estimate of Elective Service Paid to Date
(December 2004)( 483k )
2030 *
Request for Estimate of Spousal Benefit Coverage and a Reduced Pension Entitlement for a Marriage after Retirement
(May 2005)( 414k )
2476 *
Request for Pension Benefits Division Information with respect to a Public Service Superannuation Act Pension in Accordance with the Pension Benefits Division Act
(May 1999)( 20k )
2488
Request for Pension Benefits Divsion Information - (Members of parliament)
(January 2004) ( 162k )
2487
Request for Return of Superannuation Contributions
(July 2006)( 620k )
2577 *
Request for Service Records
(July 2004)( 88k )
2238
Request for Shipping
(October 1997)( 6k )
109
Request to Deposit Superannuation Cheques in a Financial Institution
(July 2005)( 402k )
2033 *
Requisition for Interdepartmental Settlement
(December 1996)( 11k )
8756
Requisition for Payment - Supplementary Death Benefits
(July 2006)( 1.7M )
2007 *
S To Top
Salary Service Information - Pension Support System
(July 2006)( 808k )
2020 *
Specimen Signature
(June 2004)( 66k )
GC-136
Statement of Amounts Paid From a Retirement Compensation Arrangement T4A-RCA
(December 2001)( 44k )
349-01
Statement of Amounts Paid From a Retirement Compensation Arrangement T4A-RCA
(December 2002)( 90k )
349-02
Statement of Amounts Paid From a Retirement Compensation Arrangement T4A-RCA
(January 2004)( 154k )
349-03
Statement of Amounts Paid From a Retirement Compensation Arrangement T4A-RCA
(January 2005)( 158k )
349-04
Statement of Distributions From a Retirement Compensation Arrangement - T4A-RCA
(January 2006)( 92k )
349-05 *
Statement of Amounts Paid or Credited to Non-Residents of Canada NR4
(December 2001)( 75k )
350-01
Statement of Amounts Paid or Credited to Non-Residents of Canada NR4
(December 2002)( 76k )
350-02
Statement of Amounts Paid or Credited to Non-Residents of Canada NR4
(January 2004)( 119k )
350-03
Statement of Amounts Paid or Credited to Non-Residents of Canada NR4
(January 2005)( 66k )
350-04
Statement of Amounts Paid or Credited to Non-Residents of Canada NR4
(January 2006)( 87k )
350-05 *
Statement of Earnings - Deceased Pensioner
(June 2004)( 513k )
2171 *
Statement of Investment income T5
(December 2001)( 218k )
392-01
Statement of Investment income T5
(December 2002)( 87k )
392-02
Statement of Investment income T5
(January 2004)( 126k )
392-03
Statement of Investment income T5
(January 2005)( 160k )
392-04
Statement of Investment income T5
(January 2006)( 101k )
392-05 *
Statement of Option - Leave Without Pay
(March 2005)( 334k )
2481 *
Statement of Qualifying Retroactive Lump-Sum Payment (QRLSP)
(December 2001)( 58k )
37
Statement of Qualifying Retroactive Lump-Sum Payment (QRLSP)
(January 2006)( 60k )
393-05 *
Statement of Remuneration Paid T4
(December 2001)(February 216k )
347-01
Statement of Remuneration Paid T4
(January 2003)( 83k )
347-02
Statement of Remuneration Paid T4
(January 2004)( 131k )
347-03
Statement of Remuneration Paid T4
(January 2005)( 153k )
347-04
Statement of Remuneration Paid T4
(January 2006)( 167k )
347-05 *
Statement of Remuneration Paid T4
(September 2006)( 701k )
347-06 *
Statement of Pension , Retirement , Annuity and Other Income T4A
(December 2001)( 88k )
348-01
Statement of Pension , Retirement , Annuity and Other Income T4A
(December 2002)( 89k )
348-02
Statement of Pension , Retirement , Annuity and Other Income T4A
(January 2004)( 143k )
348-03
Statement of Pension , Retirement , Annuity and Other Income T4A
(January 2005)( 153k )
348-04
Statement of Pension , Retirement , Annuity and Other Income T4A
(January 2006)( 95k )
348-05 *
Statutory Declaration - In the matter of an Application for Division of Pension Benefits under the Pension Benefits Division Act
(May 1999)( 96k )
2484
Statutory Declaration - In the Matter of Provision of Pension Benefits Information under the Pension Benefits Division Act
(May 1999)( 19k )
2483
Statutory Declaration - In the Matter of the Public Service Superannuation Act
(October 2004)( 1.5M )
2010 *
Statutory Declaration - Public Service Superannuation Act - Subsection 25(4) - Claimant's Statement
(August 2006)( 88k )
2467 *
Statutory Declaration - Public Service Superannuation Act - Subsection 25(4) - Supporting Statement
(March 2006)( 120k )
2467-1
Statutory Declaration - Public Service Superannuation Act Administration
(June 2004)( 537k )
2040
Superannuation Directorate - Pension and Deductions Paylist
(January 2000)( 18k )
7241
Superannuation Directorate - Production Control File Relocation System
(August 2002)( 7k )
2219
Superannuation Documentation Transmittal Slip
(July 2006)( 646k )
2241 *
Superannuation Remittance for Employees on Leave Without Pay
(May 2006)( 127k )
4005 *
Supplementary Death Benefit Claim Form
(August 2004)( 267k )
2223 *
Surrender of Rights Under a Government Annutiy Contract
(August 2005)( 67k )
2066 *
T To Top
Tax Credit Input Form
(February 2005)( 25k )
2053-1
Termination and Contributions Advice
(August 2005) ( 40k )
2321
Training - Advance Reimbursement Request
(April 2005)( 563k )
371 *
Transmittal Letter
(August 2004)( 839k )
2007-1 *
U To Top
Undertaking and Indemnity
(August 2005)( 300k )
535 *
Undertaking and Indemnity
(February 1997)( 11k )
536
Union Deductions - Dues and Insurance
(December 2004) ( 472k )
2584 *
V To Top
Void Cheques
(March 1996)( 6k )
7456-1
W To Top
War Service Questionnaire
(May 2004)( 85k )
2064
Withdrawal Allowance (Members of Parliament)*
(August 2005)( 578k )
4144