CFSA 100—Election to Pay for Prior Pensionable Service / Election to Repay Annuity or Pension Drawn During a Period of Elective Service

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

Plan member's personal information

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Carefully read instructions before completing

Retain a copy for your records and forward the original by registered mail to:
Government of Canada Pension Centre - Mail Facility
150 Dion Boulevard
PO Box 9500
Matane QC
G4W 0H3

(This election must be completed and forwarded to a commanding officer or other person designated by the Minister within the prescribed time limit.)

Part I—Election to Pay for Prior Pensionable Service

  1. I, ,
    ,
    ,
    hereby elect, under paragraph 6(b) or section 42 or 43 of the Canadian Forces Superannuation Act, to pay for (indicate by clicking the appropriate box):

    (If only part of a particular type of service is elected, the contributor may only elect to pay for the most recent part of that service.)

  2. I will make payment in the following manner (choose only ONE plan of payment and indicate choice by clicking the appropriate box):
    • $ the balance to be paid in monthly instalments of $ commencing 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
    • $ commencing 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, and I understand that the above plan of payment, on verification of the total amount required to pay for the service, is subject to adjustment in accordance with the Canadian Forces Superannuation Regulations
Signed at
Witness as to signature of contributor by:

Part II—Election to repay annuity or pension drawn during a period of elective service

To be completed by a contributor who was in receipt of Canadian Forces Superannuation Act annuity payments or pension payments under the Defence Services Pension Act during the one-year period of continuous full-time reserve service immediately preceding deemed re-enrolment.

  1. I,
    ,
    ,
    ,
    hereby elect, under subsection 41(4) of the Canadian Forces Superannuation Act, to repay the part of (indicate choice by clicking the appropriate box):

    during the one-year period of continuous full-time reserve service described in subsection 42(3) of the Canadian Forces Superannuation Act.

  2. I will make payment in a lump sum, within 30 days after receipt of notification of the amount due.
    on
    Witness as to signature of contributor by:

Part III—Forwarding Election

5. I certify that the above election was (click the appropriate box):
  • a date subsequent to the expiration of the period required under the Canadian Forces Supernannuation Act

Part IV—Medical Certificate—Belated Election

(This certificate is required ONLY for an election to count service for which the contributor failed to elect within one year of becoming a contributor under the Canadian Forces Superannuation Act. The medical examination shall be made within the period beginning 90 days before and ending 90 days after this election, unless otherwise authorized by the Minister.)

6. I certify that the contributor has been medically examined as to mental and physical fitness to perform duties as a member of the Canadian Forces and that the contributor (click the appropriate box)

to perform duties as a member of the Canadian Forces.

For office use only

CFSA 100 (2015-02-001)

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