CF-FC 2467-1—Statutory Declaration—Supporting statement

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.

To Witness

living at
make this declaration in support of the claim of
entitlement to survivor benefits payable in respect of the late

And do solemnly swear that

  1. I have known the claimant for and the plan member for
  2. My relationship to the claimant is My relationship to the plan member was (For example; friend, neighbor, colleague, brother, etc.)
  3. I became aware that the claimant was living with the plan member on or about
  4. I am aware of the following breaks in the relationship of the claimant and the plan member during the period from the date indicated in Statement 3 to the date of the plan member's death for the following reasons:
    From (YYYY-MM-DD) To (YYYY-MM-DD) Reason (if known)
  5. Please describe the extent of your knowledge of the relationship between the claimant and the plan member. If necessary, please attach additional pages.

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

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)


Statutory Declaration
Canadian Forces Superannuation Act Subsections 29(1)—Supporting Statement


  1. For the purposes of Statement 5, please include details concerning your knowledge and to what extent the claimant and the plan member shared finances, shared ownership of property and household items, shared domestic responsibilities, participated jointly in social or recreational activities and shared responsibility for children (if applicable), and explain how they each represented their relationship to family, friends, colleagues and to others in the community. Please address the following items or any other relevant details.
    1. the daily personal relationship of the claimant and the plan member and their care of each other;
    2. their joint participation in neighbourhood or community activities and with each other's families and how those families behaved toward each of them;
    3. the attitude and conduct of the community towards them both as a couple;
    4. the financial arrangements between them with respect to household expenses and ownership of property; and
    5. their attitude and conduct concerning the responsibility for children in their care
  2. If there is not enough space on the declaration form to answer a question fully, attach additional pages and in the response to that question on the form, indicate how many pages are attached. Each attached page must be initialed by you and by the person before whom the statement is being sworn

CF-FC 2467-1E (2014-12-001)

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