CFSA 103—Canadian Forces Superannuation Act
Election to Surrender Annuity or Annual Allowance under Public Service Superannuation Act or Royal Canadian Mounted Police Superannuation Act

CFSA 103—Canadian Forces Superannuation Act
Election to Surrender Annuity or Annual Allowance under Public Service Superannuation Act or Royal Canadian Mounted Police Superannuation Act ( PDF, 946KB)

Protected "B" when completed

Privacy notice

Provision of the personal information is required pursuant to the Department of Public Works and Government Services Act, para. 7(1)( d) and s.13 and will be used for the purpose of administrating the Canadian Forces Superannuation Act (CFSA). Refusal to provide the personal information, or the provision of incorrect information may result in loss of benefits and/or delays in processing, incorrect pension estimates, benefits, or statements. Personal information is protected, and only used and disclosed in accordance with the Privacy Act and as described in Personal Information Bank PWGSC PCU 702 – Federal Pension Administration. Under the Act, individuals have a right of access to their personal information and request correction, if erroneous or incomplete.

Note

This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.

Plan member's personal information

Preferred language

Part I—Election and Plan of Payment

  1. I elect in respect of my pensionable service described in subsection 46(2) of the Canadian Forces Superannuation Act (CFSA), to surrender my right to an annuity or annual allowance under (indicate choice in the appropriate box):

    OR

    I understand that in so electing I, or any person to whom any benefit might otherwise have become payable under the indicated Act, in respect of this service, will cease to be entitled to any benefit under that subsection.

  2. I will pay any amount remaining unpaid for the above service in the following manner (choose only ONE plan of payment and indicate choice in the appropriate box):

    OR

    the balance to be paid in monthly installments of $  starting on the first day of the month following the month in which this election is made and continuing until the total amount required to pay for the service and interest is fully paid

    OR

    $  starting on the first day of the month following the month in which this election is made and continuing until the total arrears of contributions and interest are fully paid

    I understand that the above plan of payment, will be verified and may be subject to adjustment under the Canadian Forces Superannuation Act.

Signed at
Witnessed as to signature of contributor by

Note

When completed retain a copy and forward the original to

Public Works and Government Services Canada
Government of Canada Pension Centre - Mail Facility
150 Dion Boulevard
PO Box 9500
Matane QC  G4W 0H3

For office use only

CFSA 103 (2018-02)

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