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Part 7: Annual Yearend
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Pension Calculator
Separation Notice (Form #10.W)
Employee Information
Last Name
First Name
Date of Birth
Address
City
Province
Postal Code
Separation Information
Type Of Separation
Termination/Resignation
Retirement
Death
Executor Contact Information
Last Name
First Name
Address
City
Phone Number
Postal Code
Date of Separation (YYYY-MM-DD)
Was this employee on a leave of absence or lay off prior to the date of separation?
Yes
No
Last Day Worked (YYYY-MM-DD)
Basic Life Insurance & Disability Income Plan
Did this employee contribute to Basic Life Insurance to the Date of Separation?
Yes
No
Not Applicable
Did this employee contribute to the Disability Income Plan?
Yes
No
Not Applicable
Payroll Information
Hourly Rate of Pay
or Annual Salary
How many pay periods are there in the year of separation?
1st Pay Period Start Date (YYYY-MM-DD)
During the year, did the employee receive any vacation pay?
Yes
No
How much?
Was the vacation pay pensionable?
Yes
No
Were the vacation hours pensionable?
Yes
No
Pensionable Service for the current calendar year (separation year)
A) Current Year Total Pensionable Hours Worked
B) Current Year Base Hours
C) Current Year Pensionable Service = A/B
If employee was Full time, were there any unpaid LOA/non-pensionable hours in the year of separation?
Yes
No
If yes, how many hours?
Pensionable Earnings and Contributions paid in the current calendar year (separation year)
Current Year Pensionable Earning
Required Employee Pension Contributions
Year's Retro Pay Was Paid For
Retro Pensionable Earnings
Retro Required Employee Pension Contributions
Total Pensionable Earnings
Total Required Employee Pension Contributions
Employer Information
Employer Number
Employer Name
Name of Contact Person
Email
Phone
Comments
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