CF-FC 2488—Request for Pension Benefits Division Information with respect to a Canadian Forces Superannuation Act Pension in Accordance with the Pension Benefits Division Act

Protected "B" when completed

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

A. Applicant

I am applying as the1

Personal representative of the1

B. Address to Which Pension Benefits Division Information is to Be Sent

C. Plan Member

D. Confirmation of beneficiary status for supplementary death benefit
(only if stipulated in an attached Court Order or written Agreement)

I hereby request confirmation as to whether the person named in the attached document is the designated beneficiary of the plan member's Supplementary Death Benefit under the Public Service Superannuation Act (PSSA). In support of this request, I have attached a certified true copy of a Court Order or written Agreement stating that I am to be named the beneficiary, or that I am entitled to this confirmation.

E. Supporting documents

F. 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.

CF-FC 2488E (2014-12-001)

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