Payment Transmittal Form - Public Works And Government Services Canada

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Public Works and Government
Travaux publics et Services
PROTECTED "B" when completed
Services Canada
gouvernementaux Canada
PAYMENT TRANSMITTAL FORM
Privacy Notice
Provision of the personal information is required pursuant to the Department of Public Works and
Government Services Act, para. 7(1)(d) and s.13 and will be used for the purpose of administrating the
Royal Canadian Mounted Police Superannuation Act (RCMPSA) and the Royal Canadian Mounted Police
Pension Continuation Act (RCMPPCA). Refusal to provide the personal information, or the provision of
incorrect information may result in loss of benefits and/or delays in processing incorrect pension
estimates, benefits, or statements. Personal information is protected, and only used and disclosed in
accordance with the Privacy Act and as described in Personal Information Bank PWGSC PCU 702 –
Federal Pension Administration. Under the Act, individuals have a right of access to their personal
information and request correction, if erroneous or incomplete.
This form must be completed electronically. If not possible, please complete it in dark ink using capital
letters.
Plan Member's Personal Information
Surname
Regimental Number
Given Names
Pension Number
Preferred Telephone Number
Date of Birth (YYYYMMDD)
Preferred Language
English
French
Home Address
Apartment Number
City
Province
Postal Code
Country
Email address (optional)
Form Number
Case Number
FOR OFFICE USE
u
ONLY
RCMP-GRC 570E (2014-07-001)
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STDHDR

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