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

Election not to Contribute

To the President of the Treasury Board, OTTAWA

I (full name) of

in the Province of hereby elect, under subsection 9(1) of the Lieutenant Governors Superannuation Act not to contribute under the Act.

I understand, thereby, that I am not entitled to any benefits under the Lieutenant Governors Superannuation Act other than a return of contributions made pursuant to sections 4, 5 or 13 of that Act, without interest.

I understand, further, that this election is irrevocable.

Signed at this day of , 19 .

WitnessSignature of Lieutenant Governor