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Canadian Forces Special Election Regulations (C.R.C., c. 395)

Regulations are current to 2024-03-06

SCHEDULE(Section 4)

CFSA 109

Canadian Forces Superannuation Act

Election to Become a Contributor

(This form is ONLY for use by a member of the forces who is subject to the Defence Services Pension Continuation Act and who elects to become a contributor under the Canadian Forces Superannuation Act within one year of the day on which he is informed by the Minister of his right to so elect.)

PART IElection and Plan of Payment

  • 1 I, blank line

    (Full given names followed by surname)

    Service No. blank line Rank blank line

    Ship, Unit or Station blank line

    Date of Birth blank line Marital Status blank line

    (Day) (Month) (year)blank line(Single, Married,  Divorced, etc.)

    being a member of the forces to whom the Defence Services Pension Continuation Act applies, hereby elect to become a contributor under the Canadian Forces Superannuation Act (CFSA) this date. I understand that I am entitled to count as pensionable service any period of service that I was entitled to count for pension purposes under Part I, II or III of the former Act together with any period of service I would have been entitled to count under Part V of the Defence Services Pension Act or Part V of the Militia Pension Act and that upon the making of this election I shall be deemed to have elected to pay for that service.

  • 2 I will make payment in the following manner (choose only ONE plan of payment and indicate choice by placing X in the appropriate block):

    • □ (a) by lump sum payment from personal funds or DVA Re-establishment Credit; OR

    • □ (b) by lump sum payment in partial settlement of arrears from personal funds or DVA Re-establishment Credit in the amount of $blank line; the balance to be paid in monthly instalments of $blank line commencing the first day of the month following the month in which the election is made and continuing until the total arrears of contributions are fully paid; OR

    • □ (c) by monthly instalment of $blank line commencing the first day of the month following the month in which this election is made and continuing until the total arrears of contributions are fully paid;

    and I understand that the above plan of payment, upon verification of the total arrears of contributions, is subject to adjustment in accordance with Canadian Forces Superannuation Regulations.

    Signed (and forwarded) at blank line this blank line

    blank line(Place)

    day of blank line 19blank line

    (Date of Election)blank line

    Witnessed as to signature of elector by

    blank line

    (Signature of Witness)blank line(Signature of Elector)

PART IIForwarding of Election

  • 3 The circumstances of the forwarding of the above election having been ascertained, I am satisfied that it was (indicate by placing X in the appropriate block):

    • □ (a) FORWARDED to me within one year of the day on which he was informed by the Minister of his right to so elect; OR

    • □ (b) NOT FORWARDED to me until the blank line day of blank line 19blank line, a date subsequent to one year of the day on which he was informed by the Minister of his right to so elect.

    blank line

    (Commanding Officer or Authority designated by the Minister)

    blank line

    (Date)

    blank line

    (Ship, Unit or Station)

 

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