CF-FC 2486—Application for Division of Pension of a Canadian Forces Superannuation Act Pension Benefits in Accordance with the Pension Benefits Division Act

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Privacy notice

Provision of the personal information including the social insurance number (SIN) 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 supplementary death benefits, Canada Revenue Agency (CRA)/Revenu Québec (RQ) reporting and 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.

Note: Every person who knowingly makes a false or misleading representation in any application or other proceeding under the Pension Benefits Division Act is guilty of an offence punishable on summary conviction.

Plan member's personal information

Preferred language

A. Plan Member

B. Current or Former Spouse / Common-Law Partner of Plan Member

C. Applicant

I am applying as the

Personal representative of the1

D. Supporting Documents

E. Applicant's Signature

I hereby apply for the division of the pension benefits accrued to the plan member named herein under the Canadian Forces Superannuation Act in accordance with the Pension Benefits Division Act.

The completed application and supporting documents are to be returned to:

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

For office use only

CF-FC 2486E (2014-11-001)

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