Canadian Forces Special Election Regulations (C.R.C., c. 395)

CFSA 109

Canadian Forces Superannuation Act

Election to Become a Contributor

(This form is ONLY for use by a member of the forces who is subject to the Defence Services Pension Continuation Act and who elects to become a contributor under the Canadian Forces Superannuation Act within one year of the day on which he is informed by the Minister of his right to so elect.)

PART IElection and Plan of Payment

• 1 I,

  (Full given names followed by surname)

  Service No. Rank

  Ship, Unit or Station

  Date of Birth Marital Status

  (Day) (Month) (year)(Single, Married,  Divorced, etc.)

  being a member of the forces to whom the Defence Services Pension Continuation Act applies, hereby elect to become a contributor under the Canadian Forces Superannuation Act (CFSA) this date. I understand that I am entitled to count as pensionable service any period of service that I was entitled to count for pension purposes under Part I, II or III of the former Act together with any period of service I would have been entitled to count under Part V of the Defence Services Pension Act or Part V of the Militia Pension Act and that upon the making of this election I shall be deemed to have elected to pay for that service.

• 2 I will make payment in the following manner (choose only ONE plan of payment and indicate choice by placing X in the appropriate block):

  • □ (a) by lump sum payment from personal funds or DVA Re-establishment Credit; OR

  • □ (b) by lump sum payment in partial settlement of arrears from personal funds or DVA Re-establishment Credit in the amount of $; the balance to be paid in monthly instalments of $ commencing the first day of the month following the month in which the election is made and continuing until the total arrears of contributions are fully paid; OR

  • □ (c) by monthly instalment of $ commencing the first day of the month following the month in which this election is made and continuing until the total arrears of contributions are fully paid;

  and I understand that the above plan of payment, upon verification of the total arrears of contributions, is subject to adjustment in accordance with Canadian Forces Superannuation Regulations.

  Signed (and forwarded) at this

  (Place)

  day of 19

  (Date of Election)

  Witnessed as to signature of elector by

  

  (Signature of Witness)(Signature of Elector)

PART IIForwarding of Election

• 3 The circumstances of the forwarding of the above election having been ascertained, I am satisfied that it was (indicate by placing X in the appropriate block):

  • □ (a) FORWARDED to me within one year of the day on which he was informed by the Minister of his right to so elect; OR

  • □ (b) NOT FORWARDED to me until the day of 19, a date subsequent to one year of the day on which he was informed by the Minister of his right to so elect.

  	(Commanding Officer or Authority designated by the Minister)
  (Date)	(Ship, Unit or Station)