Form PAW41802 "Employee Benefits Application" - Canada

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PROTECTED A (When Completed)
PAW 41802 (2019-2020)
Page 1 of 2
EMPLOYEE BENEFITS APPLICATION
Privacy Act Statement
This statement explains the purposes for the collection and use of personal information. Only information needed to respond to program requirements will
be requested. Collection and use of personal information are in accordance with the Privacy Act. In some cases, information may be disclosed without your
consent pursuant to subsection 8(2) of the
Privacy
Act. The collection and use of your personal information for the Governance Capacity Programs are
authorized by section 4 of the
Department of Indian Affairs and Northern Development
Act, R.S.C., 1985, c. I-6, and s. 122 (1), 123 (1) and 124 (1) of the
Financial Administration Act
and required for your participation. We will use your personal information for evaluation purposes in order to respond to your
Employee Benefits Application. The information collected is described in
Personal Information Bank AANDC PPU 300
(http://www.aadnc-aandc.gc.ca/
eng/1100100011039/1100100011040), and will be retained for a period of 30 years and then the records are transferred to the Library and Archives
Canada. As stated in the Privacy Act, you have the right to access your personal information and request changes to incorrect information. Contact the
Public Enquiries Contact Centre at 1-800-567-9604 to notify us about incorrect information. For more information on privacy issues and the Privacy Act in
general, you may consult the Privacy Commissioner at 1-800-282-1376.
Identification
Recipient Name
Recipient Number
Region
Contact
Given Name
Family Name
Title
Telephone Number
Email Address
Application Information
Multi-Employer Plan
Underwriter or Administrator
Indicate which condition applies to you from the following three options:
1. We are currently receiving Employee Benefits funding and estimated expenditures on PPP and CPP/QPP employer contributions
towards eligible employees for the current fiscal year will be similar (within 10%) to the previous fiscal year's expenses.
2. We are currently receiving Employee Benefits funding and estimate that expenditures on PPP and CPP/QPP employer
contributions towards eligible employees for the current fiscal year will be significantly different from the previous fiscal year's
expenditures.
3. We are not currently receiving Employee Benefits funding.
Select at least one of the following two options:
3(a) Our new Employee Benefits application only includes funding for CPP/QPP employer contributions, for CPP/QPP eligible
employees.
3(b) Our new Employee Benefits application includes funding for an employer sponsored Private Pension Plan. We are in the
process of seeking approval from the appropriate Federal or Provincial Pension Plan regulator to register this pension plan,
or the regulator has already registered our pension plan. We have attached documentation of our communication with the
regulator.
The Pension Plan is in good standing with the appropriate Federal or Provincial Pension Plan regulator:
Yes
No
N/A (CPP/QPP only)
Employee Contributions - Defined Contribution Plans
Employee contributions are of equal or greater value than employer contributions as per the Employee Benefits Program Policy:
Yes
No
N/A
Defined Benefit Plans
Employer contributions to the Defined Benefit pension plan are at the rate determined by the most recent Actuarial Valuation:
Yes
No
N/A
PROTECTED A (When Completed)
PAW 41802 (2019-2020)
Page 1 of 2
EMPLOYEE BENEFITS APPLICATION
Privacy Act Statement
This statement explains the purposes for the collection and use of personal information. Only information needed to respond to program requirements will
be requested. Collection and use of personal information are in accordance with the Privacy Act. In some cases, information may be disclosed without your
consent pursuant to subsection 8(2) of the
Privacy
Act. The collection and use of your personal information for the Governance Capacity Programs are
authorized by section 4 of the
Department of Indian Affairs and Northern Development
Act, R.S.C., 1985, c. I-6, and s. 122 (1), 123 (1) and 124 (1) of the
Financial Administration Act
and required for your participation. We will use your personal information for evaluation purposes in order to respond to your
Employee Benefits Application. The information collected is described in
Personal Information Bank AANDC PPU 300
(http://www.aadnc-aandc.gc.ca/
eng/1100100011039/1100100011040), and will be retained for a period of 30 years and then the records are transferred to the Library and Archives
Canada. As stated in the Privacy Act, you have the right to access your personal information and request changes to incorrect information. Contact the
Public Enquiries Contact Centre at 1-800-567-9604 to notify us about incorrect information. For more information on privacy issues and the Privacy Act in
general, you may consult the Privacy Commissioner at 1-800-282-1376.
Identification
Recipient Name
Recipient Number
Region
Contact
Given Name
Family Name
Title
Telephone Number
Email Address
Application Information
Multi-Employer Plan
Underwriter or Administrator
Indicate which condition applies to you from the following three options:
1. We are currently receiving Employee Benefits funding and estimated expenditures on PPP and CPP/QPP employer contributions
towards eligible employees for the current fiscal year will be similar (within 10%) to the previous fiscal year's expenses.
2. We are currently receiving Employee Benefits funding and estimate that expenditures on PPP and CPP/QPP employer
contributions towards eligible employees for the current fiscal year will be significantly different from the previous fiscal year's
expenditures.
3. We are not currently receiving Employee Benefits funding.
Select at least one of the following two options:
3(a) Our new Employee Benefits application only includes funding for CPP/QPP employer contributions, for CPP/QPP eligible
employees.
3(b) Our new Employee Benefits application includes funding for an employer sponsored Private Pension Plan. We are in the
process of seeking approval from the appropriate Federal or Provincial Pension Plan regulator to register this pension plan,
or the regulator has already registered our pension plan. We have attached documentation of our communication with the
regulator.
The Pension Plan is in good standing with the appropriate Federal or Provincial Pension Plan regulator:
Yes
No
N/A (CPP/QPP only)
Employee Contributions - Defined Contribution Plans
Employee contributions are of equal or greater value than employer contributions as per the Employee Benefits Program Policy:
Yes
No
N/A
Defined Benefit Plans
Employer contributions to the Defined Benefit pension plan are at the rate determined by the most recent Actuarial Valuation:
Yes
No
N/A
PROTECTED A (When Completed)
PAW 41802 (2019-2020)
Page 2 of 2
Supporting Documents
(if applicable)
Title
Submission Method
Declaration
The information provided is accurate to the best of my knowledge.
Given Name
Family Name
Title
Date
(YYYYMMDD)
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