CFSA 106—Canadian Forces Superannuation Act
Surrender of Right to Count Pensionable Service Without Pay

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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.

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To be completed by a contributor who does not wish to contribute in respect of the portion of a period of service in excess of 3 months in respect of which no pay was authorized (e.g., leave without pay), pursuant to s. 6.1(1) of the Canadian Forces Superannuation Act and s. 11(2.2) of the Canadian Forces Superannuation Regulations. The election must be signed within 90 days after the end of such service or within 90 days after the day on which the contributor is required to resume making contributions under the Act, whichever is later. A separate form must be completed for each period in excess of 3 months in respect of which no pay authorized.

Part I—Surrender of Right

  1. I,
    hereby surrender my right to count as pensionable service the period
    both dates inclusive, which is the portion of a period of service that is in excess of 3 months and in respect of which no pay was authorized to be paid to me because
  2. The entire period of service for which no pay was authorized, including the first 3 months for which contributions must be paid, is the period
  3. I understand that the period of service described in section 1, which is the portion in excess of 3 months, will not be counted as pensionable service for computing any benefit under the Canadian Forces Superannuation Act. Signed at
    Witness as to signature of contributor by

Part II—Forwarding of Election

4. I certify that the above election was (indicate by clicking the appropriate block):
  • a date subsequent to the expiration of the period prescribed for the making of this election

Retain a copy for your records and return the original form to the Pension Centre at the address below:

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

For office use only

CFSA 106 (2014-11-001)

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