Service PROTECTED B (when completed)
Personal Information Banks
Canada ESDC PPU 116, 146 and 175
Agreement to administer benefits under the Old Age Security Act
and/or the Canada Pension Plan by a Private Trustee
Trustees must maintain yearly records of the monies received and spent for our beneficiaries. Should
the Minister want an accounting report, the trustee must provide the requested documentation for the
applicable year(s).
Beneficiary's
It is very important that you: Social Insurance Number
- use a pen and print as clearly as possible.
The information contained on this form is essential for payments of benefits under the Old Age Security Act and/or the Canada
Pension Plan to persons acting on behalf of a beneficiary who is incapable of managing his/her own affairs. It is retained in the
information bank relating to the benefit being paid. Under the Privacy Act, the beneficiary has the right to request a copy of this record.
Old Age Security and/or Canada Pension Plan beneficiary
Mr. Mrs. Usual First Name and Initial Last Name
Ms. Miss
Home Address - No., Street, Apt., P.O. Box, R.R. and City Province or Territory
Country - If other than Canada Postal Code
I, the undersigned, agree to receive benefits under the Old Age Security Act and/or the Canada Pension Plan payable to the
beneficiary named above and undertake, following the relevant provisions and Regulations, without charge:
1. to act on behalf of the beneficiary and, in accordance with any directions, from Employment and Social Development Canada, to
administer and expend the benefits in his/her best interests;
2. to complete an accounting report for all benefits received and the payments made from them, upon request from Employment and
Social Development Canada;
3. to notify Employment and Social Development Canada if the beneficiary changes address, becomes absent from Canada, dies,
ceases to be incapable of managing his/her own affairs or if the trusteeship ends. And to provide any other information or
evidence, and to do anything that the Old Age Security Act and/or the Canada Pension Plan or their Regulations would require
from the beneficiary; and
4. to return uncashed, if the beneficiary should die, all his/her Old Age Security and/or Canada Pension Plan benefit payments which
remain uncashed at the time of his/her death or which may be issued after the month of death, and to reimburse Her Majesty the
Queen in Right of Canada for any loss sustained by her through the cashing of such payments.
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 the Old Age Security Act, or may be charged with an offence. Any benefits you received or
obtained to which there was no entitlement would have to be repaid.
IN WITNESS WHEREOF, I execute this document under seal this day of of the year .
Signed, Sealed and Delivered in the presence of
Signature of Trustee Signature of Witness
Name of Trustee - Please print Name of Witness - Please print
Address of Trustee - No., St., Apt., P.O. Box, R.R. Address of Witness - No., St., Apt., P.O. Box, R.R.
City, Town or Village Province or Territory City, Town or Village Province or Territory
Country Postal Code Telephone number Country Postal Code Telephone number
Relationship, if any, to the Beneficiary Occupation of Witness
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada.
SC ISP-3506 (2014-08-01) E Disponible en français
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
NEW BRUNSWICK AND QUEBEC CANADA
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
ONTARIO CANADA
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
