CF-FC 2223—Supplementary Death Benefit Beneficiary Information

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Privacy notice

Provision of the personal information including the social insurance number (SIN) 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 supplementary death benefits, Canada Revenue Agency (CRA)/Revenu Québec (RQ) reporting and 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

Rank

Surname

Given Names

Plan member's personal information Pension Number

Date of Birth (YYYY-MM-DD)

Preferred language

English French

Service Number

Home address

Apartment Number

Preferred Telephone Number (999‑999‑9999)

City

Province

Postal Code

Country

Email Address (optional)

Beneficiary information

Name of Beneficiary

Social Insurance Number

Date of Birth (YYYY-MM-DD)

Current Mailing Address

Telephone Number

Date of Designation (YYYY-MM-DD)

This is to certify that on the date of designation I was residing at the address below.

Address:

To the best of my knowledge, I am the person designated as the beneficiary of the late:

(Late Member's Name)

Signed at:

(City, Town or Village)

this (Day) Day of (Month) , (Year) .

(Signature of Beneficiary)

(Signature of Witness)

For office use only

Form Number

Case Number

Service Number

Pension Number

CF-FC 2196E (2015-04-001)

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Date modified:: 2020-12-16

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