Lieutenant Governors Superannuation Regulations (C.R.C., c. 1022)

Election to Contribute for Prior Service

To the President of the Treasury Board, OTTAWA

I (full name) of

in the Province of hereby elect, under subsection 5(1) of the Lieutenant Governors Superannuation Act to contribute in respect of my period of prior service as the lieutenant governor of a province as follows:

• ☐ 

  for the full period of such prior service

  or

  • ☐ 

    for part only of such prior service, that is most recent in point of time, as herein specified.

years and days or dates from/to

I further elect to make contributions for such prior service in the following manner:

• ☐ 

  lump sum

  and/or

  • ☐ 

    monthly instalments of $ deducted from my salary payments.

Signed at this day of , 19 .

WitnessSignature of Lieutenant Governor