Social Insurance No.:

Superannuation No.:

I, , hereby make application under section 10(4) of the Public Service Superannuation Act for an increase in the annuity payable to me under the Public Service Superannuation Act.

I attach to this form a statement from the Canada Pension Plan (or Quebec Pension Plan) setting forth the amount of retirement (or disability) allowance payable to me.

Further, I hereby give my authority for the release of information to the Superannuation Branch, Department of Finance, if required, concerning any aspect of my earnings, contributions, or benefits under the Canada Pension Plan (or Quebec Pension Plan).