CF-FC 2467—Statutory Declaration—Claimant's 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 for the purpose of establishing entitlement to survivor benefits payable in respect of the late

And do solemnly swear that

  1. I commenced living with the plan member on

  2. I did not live with the plan member during the following periods for the following reasons:
    From (YYYY-MM-DD) To (YYYY-MM-DD) Reason
  3. I lived with the plan member at the following addresses (listing the most recent address first):
    Full Address From (YYYY-MM-DD) To (YYYY-MM-DD)
  4. The details of my relationship with the plan member during the period of our cohabitation are as follows (see following page for instructions and attach additional pages if necessary):
  5. The following steps were taken to formalize our relationship in order to protect our status as a couple (e.g. cohabitation agreement, power of attorney, authorization to make medical decisions on behalf of your partner, etc.).
  6. I have submitted an application for survivor benefits in respect of this plan member under the following other federal superannuation acts (see instructions below for list of acts).

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)



  1. Examples of the types of details required for Statement 5 concern how and to what extent you 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). Explain how you each represented your relationship to family, friends, colleagues, and to others in the community. Please address the following items and any additional information that you consider relevant to your claim:
    1. The daily personal relationship with the plan member and care of each other;
    2. Joint participation in neighbourhood or community activities with the plan member and with each other's families and how those families behaved toward you;
    3. The attitude and conduct of the community towards you both as a couple;
    4. The financial arrangements between you and the plan member with respect to household expenses and ownership of property;
    5. Your attitude and conduct concerning your responsibility for children in your care.
  2. Other federal superannuation acts (for Statement 7):
    • Public Service Superannuation Act
    • Royal Canadian Mounted Police Superannuation Act
    • Members of Parliament Retiring Allowances Act
    • Diplomatic Service (Special) Superannuation Act
    • Lieutenant Governors Superannuation Act
    • Governor General's Act
    • Judges Act
  3. 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 2467E (2014-10-001)

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