CF-FC 2484—Statutory Declaration in the matter of an application of Pension Division Benefits

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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

Complete Section 1 if you were married, and/or complete Section 2 if you resided together in a conjugal relationship or if you were married and resided together in a conjugal relationship prior to the marriage. You must complete Section 3 and have this document sworn before a Commissioner for Oaths.

Note: Every person who knowingly makes a false or misleading representation in any application or other proceeding under the Pension Benefits Division Act (PBDA) is guilty of an offence punishable on summary conviction.

Section 1—Married

Complete this section only if the member and the spouse are or were married.

I,  , declare that I married   on  

(Check the applicable box)

  • We have lived separate and apart since We were divorced on .
  • We have lived separate and apart since .

Section 2—Not Married

Complete this section if you resided together in a conjugal relationship or if you resided together in a conjugal relationship prior to your marriage.

I,  , declare that I started living with   in a conjugal relationship on  
  • .

Section 3—During the period we were married or we lived together in a conjugal relationship, as noted above

(Check the applicable box)

(Indicate all breaks - Attach a seperate sheet if necessary)

From To
From To

I make this solemn declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.

Declared before me at
on

Signature of person authorized to take a Statutory Declaration. (Indicate whether a Justice of the Peace, Notary, Lawyer, Commissioner of Oaths (expiry date must be indicated), etc. and use stamp or seal)

on

CF-FC 2484E (2015-02-001)

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