Form SC ISP-1640 "Child Rearing Provision Canada Pension Plan" - Canada

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Download Form SC ISP-1640 "Child Rearing Provision Canada Pension Plan" - Canada

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Service
PROTECTED B (when completed)
Canada
Personal Information Banks
ESDC PPU 140, 146 and 175
Child Rearing Provision
Canada Pension Plan
If you are requesting the Child Rearing Provision on your behalf, please provide your Social Insurance Number and
name in number 1 and 2 below. If you are requesting the provision on behalf of a person who is deceased, please
provide the Social Insurance Number and name of the deceased in number 1 and 2 below.
1. Social Insurance Number 2A. Optional
2B. First name, initial and last name
Mr.
Mrs.
Ms.
Miss
3. Information about the children
List all children born after December 31, 1958.
If the child was born outside
Canada, tell us the date the
Child's Full Name
Child's SlN
Child's Date of Birth
child entered Canada
YYYY-MM-DD
YYYY-MM-DD
a)
b)
c)
d)
Should you need to list more children, use a separate sheet, answer the questions for each additional child, sign
the sheet, indicate your (or the deceased's) Social Insurance Number and attach the sheet to this form.
Were you the primary caregiver for these children from birth until age 7?
Yes
No
If no, please list any periods of time where you were not the primary caregiver and provide a reason:
From:
(YYYY-MM)
To:
From:
To:
(YYYY-MM)
(YYYY-MM)
(YYYY-MM)
Reason:
Reason:
Did you or your spouse or common-law partner receive Family Allowances or
Yes
No
Canada Child Tax Benefits for these children?
If yes, please indicate who received the benefits:
You
Your spouse or common-law partner
List any periods of time while the children were under the age of seven and when you did not receive Family
Allowances or Canada Child Tax Benefits and provide a reason. Do not list periods of time when you were eligible
for the Canada Child Tax Benefit, but did not receive it because your family income was too high.
From:
To:
(YYYY-MM)
(YYYY-MM)
From:
To:
(YYYY-MM)
(YYYY-MM)
Reason:
Reason:
Note: If you did not provide a Social Insurance Number for each child, or if any of the children were
born abroad, please refer to the Information sheet under section "Documents required".
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada
SC ISP-1640 (2018-12-05) E
1 / 2
Disponible en français
Service
PROTECTED B (when completed)
Canada
Personal Information Banks
ESDC PPU 140, 146 and 175
Child Rearing Provision
Canada Pension Plan
If you are requesting the Child Rearing Provision on your behalf, please provide your Social Insurance Number and
name in number 1 and 2 below. If you are requesting the provision on behalf of a person who is deceased, please
provide the Social Insurance Number and name of the deceased in number 1 and 2 below.
1. Social Insurance Number 2A. Optional
2B. First name, initial and last name
Mr.
Mrs.
Ms.
Miss
3. Information about the children
List all children born after December 31, 1958.
If the child was born outside
Canada, tell us the date the
Child's Full Name
Child's SlN
Child's Date of Birth
child entered Canada
YYYY-MM-DD
YYYY-MM-DD
a)
b)
c)
d)
Should you need to list more children, use a separate sheet, answer the questions for each additional child, sign
the sheet, indicate your (or the deceased's) Social Insurance Number and attach the sheet to this form.
Were you the primary caregiver for these children from birth until age 7?
Yes
No
If no, please list any periods of time where you were not the primary caregiver and provide a reason:
From:
(YYYY-MM)
To:
From:
To:
(YYYY-MM)
(YYYY-MM)
(YYYY-MM)
Reason:
Reason:
Did you or your spouse or common-law partner receive Family Allowances or
Yes
No
Canada Child Tax Benefits for these children?
If yes, please indicate who received the benefits:
You
Your spouse or common-law partner
List any periods of time while the children were under the age of seven and when you did not receive Family
Allowances or Canada Child Tax Benefits and provide a reason. Do not list periods of time when you were eligible
for the Canada Child Tax Benefit, but did not receive it because your family income was too high.
From:
To:
(YYYY-MM)
(YYYY-MM)
From:
To:
(YYYY-MM)
(YYYY-MM)
Reason:
Reason:
Note: If you did not provide a Social Insurance Number for each child, or if any of the children were
born abroad, please refer to the Information sheet under section "Documents required".
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada
SC ISP-1640 (2018-12-05) E
1 / 2
Disponible en français
Child Rearing Provision
PROTECTED B (when completed)
Social Insurance Number
Canada Pension Plan
4. Signature
I declare that, to the best of my knowledge, the information on this form is true and complete. I realize that my
personal information, or the personal information of the deceased, is governed by the Privacy Act and it can be
disclosed where authorized under the Canada Pension Plan.
NOTE: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and
interest, if any, under the Canada Pension Plan, or may be charged with an offence. Any benefits you
received or obtained to which there was no entitlement would have to be repaid.
Date
Telephone number
Signature
(YYYY-MM-DD)
NOTE: We can only accept a signature with a mark (e.g. X) if a responsible person witnesses it.
That person must also complete the declaration below.
If you are completing this form on behalf of someone who is deceased, please provide the following.
Your Name
Telephone number
Address
5. Witness's declaration
If the applicant signs with a mark, a witness (friend, member of family, etc.) must complete this section.
I have read the contents of this form to the applicant, who appeared to fully understand and who made their mark in
my presence.
Name
Relationship to applicant
Telephone number (day)
Address
Witness's signature
Date
(YYYY-MM-DD)
6. Waiver of rights to the Child Rearing Provision
To be completed only by the person who received Family Allowances payments under the
Family Allowances Act and wishes to waive all rights to the Child Rearing Provision in favour of the
spouse who remained at home and was the primary caregiver for the child(ren).
I declare that, for the child(ren) indicated in Section 3, I have not and will not make any claims for the
Child Rearing Provision for the period(s) accredited to my spouse.
Name
Social Insurance Number
Date
(YYYY-MM-DD)
Telephone number during the day
Signature
SC ISP-1640 (2018-12-05) E
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Service
Canada
Service Canada Offices
Canada Pension Plan
Mail your forms to:
The nearest Service Canada office listed below.
From outside of Canada: The Service Canada office in the province where you last resided.
Need help completing the forms?
Canada or the United States: 1-800-277-9914
All other countries: 613-957-1954 (we accept collect calls)
TTY: 1-800-255-4786
Important: Please have your social insurance number ready when you call.
NEWFOUNDLAND AND LABRADOR
ONTARIO
Service Canada
For postal codes beginning with "K or P"
PO Box 9430 Station A
Service Canada
St. John's NL
A1A 2Y5
PO Box 2013 Station Main
CANADA
Timmins ON
P4N 8C8
CANADA
PRINCE EDWARD ISLAND
Service Canada
MANITOBA AND SASKATCHEWAN
PO Box 8000 Station Central
Service Canada
Charlottetown PE
C1A 8K1
PO Box 818 Station Main
CANADA
Winnipeg MB
R3C 2N4
CANADA
NOVA SCOTIA
Service Canada
ALBERTA / NORTHWEST TERRITORIES
PO Box 1687 Station Central
AND NUNAVUT
Halifax NS
B3J 3J4
Service Canada
CANADA
PO Box 818 Station Main
Winnipeg MB
R3C 2N4
CANADA
NEW BRUNSWICK AND QUEBEC
Service Canada
PO Box 250
BRITISH COLUMBIA AND YUKON
Fredericton NB
E3B 4Z6
Service Canada
CANADA
PO Box 1177 Station CSC
Victoria BC
V8W 2V2
CANADA
ONTARIO
For postal codes beginning with "L, M or N"
Service Canada
PO Box 5100 Station D
Scarborough ON
M1R 5C8
CANADA
Disponible en français
SC ISP-3501-CPP (2018-01-18) E
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