CF-FC 578E—Revocation of Election to Pay for Prior Pensionable Service
Canadian Forces Superannuation Act

Plan member's personal information

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Part I—Request for revocation

This form is for use by a contributor who, pursuant to subsection (4) of section 8 of the Canadian Forces Superannuation Act and section 13 of the Canadian Forces Superannuation Regulations, requests revocation, in whole or in part of an election to pay for service made under that Act.)

1. I, (Full given name followed by surname) , (Service Number) , (Rank) , (Ship, Unit or Station) , hereby request that my election to pay for prior elective pensionable service, made under the Canadian Forces Superannuation Act, be revoked as to (indicate by clicking the appropriate block):
   • (a) All my prior pensionable service:
   • (b) Part only of my prior pensionable service, namely,
     (specify type and period of service for which revocation is requested.)
2. I hereby certify that the reason for this request is as follows (indicate by clicking the appropriate block):
   • (a) I received erroneous information, or misleading information in writing, from a member of the forces or a person employed in the Public Service who normally gives information as to the amount required to be paid under the Canadian Forces Superannuation Act for service, and in making the election, I honestly acted upon that information or
   • (b) Undue financial hardship, unforeseen by me at the time of making the election, will be caused to me if I am required to continue to pay for the above period of service.
3. I submit the following particulars to substantiate my request
   (use attachments if required)
4. I understand that, if my request is approved by the Minister of National Defence, I shall be required to pay to Her Majesty the amount in respect of any benefit accruing to me during the subsistence of my election, as a consequence of my having elected, as the Minister determines in accordance with Canadian Forces Superannuation Regulations.

   Signed^{Link to footnote 1} (and forwarded) at (Place) this (Day) day of (Month)  , (Year) .

   Witnessed as to signature of contributor by

   (Signature of Witness)

   (Signature of Contributor)

Part II—Forwarding of request

This form is for use by a contributor who, pursuant to subsection (4) of section 8 of the Canadian Forces Superannuation Act and section 13 of the Canadian Forces Superannuation Regulations, requests revocation, in whole or in part of an election to pay for service made under that Act.) - Part II

5. The circumstances of the forwarding of the above request having been ascertained, I am satisfied that it was (indicate by clicking the appropriate block):
   • (a) Forwarded to me within thirty days of making of his request or
   • (b) Not forwarded to me until the (Day) forward_signed_day day of (Month) , (Year) .

   a date subsequent to thirty days of the making of this request.

Part III

This form is for use by a contributor who, pursuant to subsection (4) of section 8 of the Canadian Forces Superannuation Act and section 13 of the Canadian Forces Superannuation Regulations, requests revocation, in whole or in part of an election to pay for service made under that Act.) - Part III

6. Part III
   • I hereby grant the above request effective hereby grant(Day) day of hereby grant(Month) , hereby grant(Year)
   • I hereby do not grant the above request (see attached rationale) effective hereby do not grant(Day) day of hereby do not grant(Month) , hereby do not grant(Year)