CF-FC 2010—Statutory Declaration—In the Matter of the Canadian Forces Superannuation Act

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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 is required for purposes of Section 25 of the Canadian Forces Superannuation Actand should be completed by the survivor or other person(s) having custody and control of dependant children.

In the matter of the Canadian Forces Superannuation Act

I, of

do solemnly declare:

that I am the of the late
of ,
That the dependant children (include stepchildren and adopted children) now alive of the said late plan member, and their birth dates are as follows:
That I have custody and control of all the above-named dependant children, OR the following dependant children:
I make this solemn declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.
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)

Send completed declarations to

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

CF-FC 2010E (2014-11-001)

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