0100006 LA

Consent to Release of Information

This form is for the use of anyone who wants to authorize a designated person or organization to obtain, on their behalf, confidential information
or documents concerning them held by Retraite Québec.

Please print.
1. Information on the person authorizing the release of information

Enter the Social Insurance Number of the person giving authorization:

Sex Family name Given name

F
Date of birth Mother’s family name at birth (last name only)
M year month day

Address (number, street, apartment or post office box)

City Province Country Postal code

area code area code

Telephone Extension Other

2. Information on the person or organization authorized to obtain information

Please check the box corresponding to your situation and enter the information requested.
I am acting as an individual (relative, friend, caregiver, etc.)
Sex Family name Given name Date of birth
year month day

F
Social Insurance Number Mother’s family name at birth (last name only)
M

Address (number, street, apartment or post office box)

City Province Country Postal code

area code area code

Telephone Extension Other

I belong to an organization that has an agreement with Retraite Québec authorizing me to act as an intermediary between the
person named above and Retraite Québec.
Sex Family name Given name Date of birth
year month day

F
Name of the organization
M

Address (number, street, apartment or post office box)

City Province Country Postal code

area code area code

Telephone Extension Other

(Continued on back)
Retraite Québec CRQ-001A (2019-11)
 2. Information on the person or organization authorized to obtain information (continued)

I belong to an organization that does not have an agreement with Retraite Québec.
Sex Family name (mandatory) Given name (mandatory)

F
Name of organization
M
Address (number, street, apartment or post office box)

City Province Country Postal code

area code area code

Telephone Extension  Other

3. Information covered by the authorization

This authorization allows the person or organization designated in Section 2 to obtain information on:
My Family Allowance file
My Québec Pension Plan file.
My public-sector pension plan (RREGOP, PPMP, etc.).
My application for a pension from a foreign country.
In addition, this consent allows the designated person or organization to have the address of the person giving authorization
changed. Except for organizations that have a written agreement with Retraite Québec, this is the only change allowed, and only
if the change does not affect the destination of a payment.

4. Authorization and term of consent

This authorization is valid for a maximum of twelve months from the date it is signed.
year month day

Date authorization ends if given for less than twelve months:

year month day

Signature Date
Person giving authorization

Access to documents held by public bodies and the protection of personal information
The personal information collected on this form is needed to study your application. Failure to provide the requested information
in the mandatory sections may result in a delay or a refusal to process your application. Only authorized employees have access
to the information and it is only disclosed to other persons or agencies for verification in cases provided for by law. It can also
be used for research, assessment, analysis or survey purposes. Pursuant to the Act respecting Access to documents held by
public bodies and the Protection of personal information, you may consult your personal information and have it corrected.

Send us this form and the required documents online at

www.retraitequebec.gouv.qc.ca.
Your application will be processed faster and the postal delay will be eliminated.
If you are unable to use the online service, please return the form and required documents to:
Retraite Québec, case postale 5200, Québec (Québec) G1K 7S9

Contact us:
By telephone
Québec Pension Plan
418 643-5185 (Québec area) 1 800 463-5185 (toll-free)

Save Print Public-sector pension plans

418 643-4881 (Québec area) 1 800 463-5533 (toll-free)
Retraite Québec CRQ-001A (2019-11)