Public Service Superannuation Regulations (C.R.C., c. 1358)

SUPERANNUATION BRANCH

Department of Finance

Public Service Superannuation Act

NOTICE OF COURT ORDER

Applicable to Subsection 20(2) of the

Public Service Superannuation Act

Court	Province	Date of Order
Name of Recipient	Amount and Method of Payment
	Lump Sum
	☐ $ or ☐ $ per
Name of Dependent	Relationship of Dependent to Recipient
Statute or other Authority under which Order was made

THE PRESIDENT OF THE TREASURY BOARD

OTTAWA, CANADA.

In compliance with the above-mentioned order, (a certified copy of which is attached hereto), and pursuant to subsection 20(2) of the Public Service Superannuation Act, I hereby request that you pay the amount specified herein to the above-named dependent by deductions from any amount that is or becomes payable to the recipient under the Public Service Superannuation Act.

Form No.