Accord Canada-Malte

Accord Canada-Malte
Demande de prestation de survivant maltaise
Voici des renseignements importants dont vous devez tenir compte au moment de remplir votre
demande.
Veuillez vous assurer de signer la demande. Si vous apposez une marque en guise de signature, (par
exemple : « X »), la signature d’un témoin est exigée.
Votre demande doit être accompagnée de tous les documents justificatifs requis. Veuillez soumettre ces
documents. Omettre de remplir la demande ou de fournir les documents demandés pourrait retarder le
traitement de votre demande.
Lorsqu’il est précisé qu’on exige les documents originaux, il vous faut soumettre les documents originaux
avec votre demande. Vous devez conserver, pour vos dossiers, une copie certifiée conforme de tout
document original que vous nous envoyez. Certains pays exigent des documents originaux qui ne vous
seront pas retournés.
Vous pouvez soumettre l’original ou une photocopie certifiée conforme de tout document lorsque les
originaux ne sont pas exigés. Il est préférable d’envoyer des photocopies certifiées de documents plutôt
que les originaux. Si vous nous envoyez vos documents originaux, veuillez le faire par courrier
recommandé. Nous vous retournerons tous vos originaux. Nous acceptons les photocopies seulement si
elles sont lisibles et certifiées conformes aux documents originaux. Le personnel de tout Centre Service
Canada photocopiera vos documents et les certifiera sans frais. Si vous ne pouvez visiter un Centre
Service Canada, vous pouvez demander à une des personnes suivantes de certifier vos photocopies :
avocat; chef de bande des Premières nations; comptable; directeur d’un établissement financier; employé
d’un Centre Service Canada qui agit à titre officiel; employé d’un ministère fédéral ou provincial ou de
l’une de ses agences; enseignant; entrepreneur de pompes funèbres; greffier municipal; ingénieur; juge
de paix; magistrat; maître de poste; député fédéral ou son personnel; député provincial ou son personnel;
ministre du culte; notaire; policier; professionnel de la santé : chiropraticien, dentiste, médecin,
pharmacien, psychologue, infirmier autorisé et infirmier praticien; représentant d’une ambassade, d’un
consulat ou d’un haut-commissariat; représentant d’un pays avec lequel le Canada a conclu un accord de
réciprocité en matière de sécurité sociale; travailleur social.
La personne qui certifie la photocopie doit la comparer à l’original, indiquer son poste ou son titre officiel,
écrire son nom en lettres moulées, indiquer son numéro de téléphone, inscrire la date à laquelle elle
certifie le document et le signer.
Elle doit aussi inscrire ce qui suit sur la photocopie : Photocopie conforme au document original, qui
n’a pas été modifié d’aucune façon.
Si le document a des renseignements des deux côtés, les deux côtés doivent être photocopiés et
certifiés. Vous ne pouvez pas certifier les photocopies de vos propres documents et vous ne pouvez pas
demander à un parent de le faire pour vous.
Retournez votre demande dûment remplie, les formulaires et les documents à l’appui aux :
Opérations internationales
Service Canada
CP 2710 Succursale Main
Edmonton (Alberta) T5J 2G4
CANADA
Avertissement :
Ce formulaire de demande a été élaboré
conjointement par des sources externes et Emploi et
Développement Social Canada. Le contenu et le
langage répondent aux exigences législatives de ces
sources externes.
APPLICATION
for SURVIVOR’S PENSION
38, Ordnance Street,
Valletta VLT 2000 - MALTA
Tel: 2590 3420 Fax: 2590 3282
e-mail: [email protected]
website: http://www.msp.gov.mt
Under the Social Security Agreement between
MALTA and CANADA
Application received by Service Canada Office on:
1. PERSONAL DETAILS
Maltese I.D. Number:
Maltese Social Security No:
Canadian Insurance No. (if known)
Given Name:
Surname:
Maiden Surname (in case of widow):
Address:
E-Mail:
Telephone Number:
Date of Birth:
Date of Marriage:
* Spouse’s Given Name:
* Spouse’s Surname:
(Maiden Surname in case of female spouse)
* Spouse’s Maltese I.D. No
* Spouse’s Date of Birth:
* Spouse’s Date of Death:
* Spouse’s Canadian Insurance No. (if known)
* Did the spouse’s death occur due to an accident / desease on work?
* Mandatory requirements
MARITAL STATUS AT THE TIME OF THE DEMISE:
married
divorced / separated
and provided alimony to spouse
divorced / separated
and did not provide alimony to spouse
App_WP_can_v1.5
YES
NO
CHILDREN’S INFORMATION:
Please provide details for children under 21 years of age. For children aged between 16 and 21,
please state whether they are receiving any income such as allowances, stipends, salaries, etc.
Date of Birth
Name and Surname:
Do you have
custody?
YES
NO
Income
YES
NO
If expecting a child, attach medical certificate and indicate anticipated date of birth
2. LATE SPOUSE’S INCOME DETAILS
To be filled if not in receipt of a Pension from Malta prior to death.
Last employment in Malta:
Employer / Company (1)
(1)
(2)
Grade / Designation
Year
Weekly
Income (2)
If available, please attach any relevant documentation, e.g. letter of appointment / contract, termination of
employment certificate, letter of reference by employer, statement of payee earnings, emoluments record;
If you do not remember the basic salary leave empty.
Are you receiving or expecting to receive a pension (other than the Service Canada pension) for services that your late
spouse rendered to one or more of his/her former EMPLOYERS (1) (inside and outside Canada). If YES please enter the
information and comply with the instruction shown hereunder.
YES
NO
If YES:
From where and effective date
Kindly attach documentation showing the amount as on the FIRST payment date of pension you are receiving or expecting
to receive.
(1) e.g. a private company pension, superannuation fund, retirement savings account, etc.
3. CANADIAN RESIDENCE
Information required to support an application for benefits under a social security agreement
Account No:
CAG
A. If born outside Canada provide:
Place of entry to Canada:
Date of entry to Canada:
B. List the places where you have lived in Canada from age 18 to present:
(If required, please provide additional information on a separate sheet of paper and attach to this form)
FROM
Month/Year
TO
Month/Year
CITY, TOWN OR VILLAGE
COUNTRY OR DISTRICT
PROVINCE OR COUNTRY
C. List all absences from Canada of more than 90 days during the periods of residence you have listed above:
(If required, please provide additional information on a separate sheet of paper and attach to this form)
DEPARTED
Day / Month / Year
RETURNED
Day / Month / Year
COUNTRY OR COUNTRIES VISITED
D. List names, addresses and telephone numbers of at least two persons not related to you by blood or marrriage,
who can confirm the facts of your residence as stated above:
(If required, please provide additional information on a separate sheet of paper and attach to this form)
NAME
ADDRESS
TELEPHONE NUMBER
E. List name(s), address(es) and telephone number(s) of your employer(s) in Canada:
(If required, please provide additional information on a separate sheet of paper and attach to this form)
NAME
ADDRESS
TELEPHONE NUMBER
4. APPLICANT’S EMPLOYMENT DECLARATION
Tick (3) if applicable:
I will keep my present employment (1)
I will terminate employment on (2)
I will start employment on (3)
Not currently in employment
(1)
(2)
(3)
You have to provide a copy of the current pay slip showing your weekly wage.
If you intend to terminate employment please provide a termination employment certificate from your employer or a letter of resignation.
Please provide a copy of the first payslip showing your weekly wage after starting employment.
5. BANK ACCOUNT DETAILS
Benefit should be deposited either in a Canadian or a Maltese Savings or Current Account but not in a Loan Account. The
account should be in the name of the beneficiary.
Acct. No.
Acct. Name.
Bank Ref. No.
Bank:
Transit No:
6. DECLARATION
•
I declare, that all information given is to my knowledge true, complete and correct. I understand that if the information
given is false, I will be penalised as stipulated by Law and may also lose the right for all or part of the benefit as stipulated
by the Maltese Social Security Act (Cap 318)
•
I authorise the Director (Benefits) Malta and Service Canada, to perform all the necessary investigations and to exchange
any necessary information to determine the correct entitlement of this benefit.
•
I bind myself to inform immediately the Director (Benefits) Malta and Service Canada, of any changes in circumstance
as indicated in this form. (eg.: if I remarry, if I start working again, if I will stop taking care of my children, if my children
are 21 years old.)
•
I am aware that if in the future it transpires that I had no right for a Widows Pension, I will have to refund to the Social
Security Division Malta, such monies for which I was not entitled.
Any missing information may entail
to a disallowance or a delay in the
process of your application.
Date
Signature
7. NECESSARY DOCUMENTS
Marriage Certificate
Spouse’s Death Certificate
Spouse’s Birth Certificate
Official documentary evidence that alimony was provided if divorced / separated
A copy of the last pay slip showing applicant’s weekly wage (to be submitted only if applicant is still in employment.)
Termination of employment certificate or a document of evidence of cessation of employment (to be submitted only
if applicant terminated employment.
Data Protection Declaration:
The Social Security Division collects all relevant personal information to provide its services to individuals who qualify for assistance,
allowance or non-contributory pensions in accordance with the Social Security Act (Cap 318). The Division may verify the information
submitted by you in line with article 133 (b) of the Social Security Act to ensure its accuracy in relation to the claim. Personal data may
be disclosed to departments / third parties, who may also have access to your data as authorised by law. Personal information may also
be exchanged with benefits institutions of other countries to combat and deter fraud, as provided for in international treaties or bilateral
agreements to which Malta is a party. You will be informed in due course of the result of your claim after it has been assessed.
The Social Security Division treats your personal information in accordance with the Data Protection Act, (Cap 440) to protect your privacy.
You may request in writing to access information held about you, and eventually to rectify, and where applicable to erase incorrect
information, having regard to the claim for which you applied. Such request is to be addressed to: “The Data Controller” at the Division
and appropriate action would be taken at the earliest possible time. In making such requests, kindly quote your identity card number,
national insurance number, your name and address and other relevant documentation to identify your case.
Accord Canada / Malte
Documents et/ou renseignements nécessaires à l’appui de votre
demande [App_WP_can_v1.5]
de pension de survivant maltaise
Documents originaux ou copies certifiées à produire :
• Certificat de naissance (personne décédée, époux/épouse, enfants à charge)
• Certificat de décès
• Preuves des dates d’entrée(s) au Canada et de départ(s) du Canada de la personne
décédée (p. ex., documents d’immigration, passeport, visa, billet de bateau ou d’avion,
etc.)
Le cas échéant, documents originaux ou copies certifiées à produire :
• Certificat de mariage
• Si la personne décédée ne recevait pas de prestation maltaise et si disponible,
documents à l’appui de son emploi à Malte (ex. lettres d’engagement, contrats
d’emploi, certificats d’emploi, lettres d’employeurs, relevés de paie, etc.)
• Acte de séparation
• Preuve de paiement de pension alimentaire
• Si vous êtes enceinte, un certificat médical indiquant la date de naissance prévue
• Pour les prestations que vous recevez autres que du Régime de pensions du Canada et
la Sécurité de la vieillesse : preuve de la date effective et du montant du premier
paiement
• Preuves de votre statut d’emploi (p. ex., relevé de paie, lettre ou certificat de
terminaison, etc.)
IMPORTANT : Si vous avez déjà soumis n’importe lequel de ces documents à l’appui
de votre demande de prestation du Régime de pensions du Canada ou de la
Sécurité de la vieillesse, vous n’avez pas à les soumettre de nouveau.