CFSA 105—Canadian Forces Superannuation Act
Application for Reduction of Instalments

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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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(This form is for use by a contributor who, pursuant to subsection 14(4) of the Canadian Forces Superannuation Regulations, applies for a reduction in the amount of his monthly instalments in respect of an election made under the Canadian Forces Superannuation Act (CFSA) to pay for elective pensionable service.)

Part I—Application for Reduction

  1. I,
    hereby apply to reduce my instalments to pay for prior elective pensionable service, in respect of my election under the CFSA
     $ 
     $ 
    monthly.
  2. I certify that the reason for this application is that undue financial hardship, which was unforeseen by me at the time of making my election, will be caused to me if I am required to continue to pay at my present instalment rate and I submit the following particulars to substantiate my application (use attachments if required)
  3. I attach the following material to support this application:
Signed at
Witnessed as to signature of contributor by

Part II—Receipt of Application

  1. The foregoing application was received by me on
.

Part III—Medical Certificate

(The medical examination shall be made within a period of 90 days immediately prior to or after the application unless otherwise authorized by the Minister.)

  1. I certify that the contributor has been medically examined as to his/her mental and physical fitness to perform his/her duties as a member of the forces, and that he/she has (indicate by clicking the appropriate block):

Retain a copy for your records and return the original form to the Pension Centre at the address below:

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

For office use only

CFSA 105 (2014-10-001)

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