Plan member's personal information
Plan member's personal information Pension number
Preferred telephone number (999‑999‑9999)
Email address (optional)
Plan Member's additional information
Carefully read instructions before completing
Pensioner I hereby appoint the following beneficiary and revoke any previous designation
Relationship to plan member
Participant's signature (Must be signed in dark ink)
Witness' signature - Other than the beneficiary (Must be signed in dark ink)
Witness' name and address (Please print)
Note: You must be a plan member in the Supplementary Death Benefit (SDB) plan to complete this form; otherwise, the form will be invalid. You may cancel or change your beneficiary at any time while a plan member, whether serving or retired.
Upon your death, your named beneficiary may become entitled to certain lump sum benefits which are payable under Part II of the Canadian Forces superannuation Act. A naming takes effect the date this form is completed; however,
this form must be received by the Government of Canada Pension Centre prior to your death. Therefore, it is recommended that the completed form, be forwarded by express mail to the address indicated below. Important—You may only have one designated beneficiary at a time.
You may designate:
any person over 18 years of age on the date of naming
your Estate (print "Estate" in the space provided for the beneficiary). If you only wish to cancel the
previous designation and not name a new beneficiary, simply print "Estate"
any registered charitable, benevolent/religious or educational organization or institution (name,
address and registration number of the institution are required)
An ineligible or ambiguous designation will render the form invalid
Commanding officer (CO)'s signature
Instructions for serving members and pensioners—Completion of the form
Please complete all fields and print.
No acknowledgement receipt will be sent, please retain a copy for your records.
Service Number or Pension Number must be provided.
Amendments are not acceptable unless initialed by the participant and the witness.
Both the plan member and the witness must sign this form in
Completion of this form negates any previously submitted form on file. If the form is completed incorrectly, any supplementary death benefit will be payable to your estate unless a properly completed form naming a beneficiary is received by the Government of Canada Pension Centre.
Instructions for Serving Members Only
Reserve Force members must be on Class C service on the date of signature. A break in Class C service will cause this form to become invalid. A new form must be completed at the commencement of each period of Class C service.
It is the responsibility of the base, wing or unit to ensure the form is completed correctly. This is indicated by the stamp and/or signature of the Commanding Officer. (By stamping and/or signing, the Personnel Office or Base Orderly Room verifies the form is completed as required.)
Submit a completed copy to your Personnel Office or Base Orderly Room, who will verify it correct and forward a stamped/signed copy to the Government of Canada Pension Centre on your behalf and place a copy on your file.
Forwarding of the Form
It is important that this form be received at the address indicated below as soon as possible.
Public Works and Government Services Canada
Government of Canada Pension Centre - Mail Facility
150 Dion Boulevard
PO Box 9500
Matane QC G4W 0H3