CF-FC 1422—Deductions From Annuity or Annual Allowance

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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

Preferred language

Carefully read instructions before completing

This form must be completed to authorize deductions from your pension.

To request that no deductions be taken from your annuity, go directly to the signature section.

Plan

  1. Medical Service Plan of British Columbia

    • $  

  2. Service Income Security Insurance Plan (SISIP)

    • $  

  3. Canada Savings Bonds

    • $  

  4. United Way (see instruction 4)

    • $  

  5. Military Post-Retirement Life Insurance Plan (MPRLIP)

    • $  

  6. Pensioners' Dental Services Plan (PDSP)

    • $  

  7. Public Service Health Care Plan (PSHCP) (See instructions 2)

    • $  

  8. Other Deductions (please specify)

    • $  

Signature of Plan Member

Please check one of the following boxes:

To be completed by the Government of Canada Pension Centre

Type of Entitlement

Instructions

  1. This form is required by the Department of Public Works and Government Services Canada to assist plan members who will release and receive a monthly pension benefit to maintain an orderly flow of legal assignment payments and to minimize the inconvenience which might be caused by a delay in these payments.

    The completed form must be sent to the Government of Canada Pension Centre.
    Retain a copy for your records

  2. If you are not a member of the Public Service Health Care Plan and you would like this coverage, you must apply by completing form TBS-006492 attached that can also be obtained on the web site and mailing it to:

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

    Note: If a certificate number has already been assigned to you for a dependant, please indicate this number under item 7 above.

  3. United Way. Complete only if you currently have a United Way deduction. Unless a new pledge form is completed for the new campaign year, this deduction will cease at the end of the current calendar year

CF-FC 1422 (2014-10-001)

For office use only

CF-FC 1422E (2014-10-001)

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