Election not to Contribute
To the President of the Treasury Board, OTTAWA
I (full name) of
in the Province of hereby elect, under subsection 9(1) of the Lieutenant Governors Superannuation Act not to contribute under the Act.
I understand, thereby, that I am not entitled to any benefits under the Lieutenant Governors Superannuation Act other than a return of contributions made pursuant to sections 4, 5 or 13 of that Act, without interest.
I understand, further, that this election is irrevocable.
Signed at this day of , 19 .
WitnessSignature of Lieutenant Governor
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