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.
This form is to be completed only in cases where a recipient is unable to manage his/her own affairs or is incapable of managing his/her own affairs and there is no person entitled by law to act as his/her committee of curator.
If there is a legal committee, please send a certified copy of the court order or other instrument appointing the committee, to:
Public Works and Government Services of Canada,
Government of Canada Pension Centre - Mail Facility,
150 Dion Boulevard
PO Box 9500,
Matane QC G4W 0H3.
solemnly declare as follows:
- That I amLink to footnote1
and have knowledge that
receives a benefit under the Canadian Forces Superannuation Act
- I am aware and believe that the recipient cannot manage his or her own affairs for the reasons stated in the certificate of
marked Exhibit "A" to this declaration
- There is no person entitled by law to act as a committee of the recipient
- If the monies payable to the recipient are paid to me, I agree:
- to manage the monies for the care of the recipient and his or her dependants during the period he or she cannot manage his or her own affairs
- to indemnify and save harmless the Government of Canada from and against all claims for which it may be liable because of the payments being made to me instead of the recipient
- to notify Public Works and Government Services Canada, Government of Canada Pension Centre - Mail Facility 150 Dion Boulevard PO Box 9500 Matane QC G4W 0H3, immediately if:
- the recipient becomes able or capable of managing his or her own affairs
- the recipient dies
- Marked Exhibit "B" to this declaration is a certificate from two responsible persons. They recommend that I am a proper person to manage the payments due to the recipient under the Canadian Forces Superannuation Act
I make this solemn declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.
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)
Exhibit "A"—Certificate of Medical Practitioner
, a qualified medical practitioner residing at
Exhibit "B"—Certificate of Responsible Persons
The "Certificate of Responsible Persons" must be completed by two responsible persons not related to either the recipient or the proposed payee and not financially interested in the proposed designation. These persons should not include:
- the medical practitioner who has certified incapacity
- the person before whom the statutory declaration was sworn
- the employees of any institution being proposed as payee
We, the undersigned, are aware of the facts set out in this statement and to the best of our knowledge and ability recommend that
is the proper person or institution to control the benefits payable to
, who cannot manage his or her own affairs.
CF-FC 2040E (2014-08-001)