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Canadian Forces Superannuation Regulations

Version of the schedule from 2006-03-22 to 2016-03-28:


SCHEDULE III(Section 38)

FORM CFSA 100Canadian Forces Superannuation Act

Election to Pay for Prior Pensionable Service/Election to Repay Annuity or Pension Drawn during a Period of Elective Service

(This election must be completed and forwarded to a commanding officer or other person designated by the Minister within the prescribed time limit.)

PART IElection to Pay for Prior Pensionable Service

  • 1 I, S.N. blank line,blank line(Rank) blank line,

(Full names) blank line,

hereby elect, under paragraph 6(b) or section 42 or 43 of the Canadian Forces Superannuation Act, to pay for (indicate choice by placing an “X” in the appropriate box):

    • (a) all my prior pensionable service.

OR

    • (b) part of my prior pensionable service only, namely (specify type and period of service elected):

blank line

blank line .

(If only part of a particular type of service is elected, the contributor may only elect to pay for the most recent part of that service.)

  • 2 I will make payment in the following manner (choose only ONE plan of payment and indicate choice by placing an “X” in the appropriate box):

    • (a) by a lump sum payment,

OR

    • (b) by a lump sum payment of $ blank line, the balance to be paid in monthly instalments of $ blank line, commencing on the first day of the month following the month in which this election is made and continuing until the total amount required to pay for the service and interest is fully paid,

OR

    • (c) by monthly instalments of $ blank line, commencing on the first day of the month following the month in which this election is made and continuing until the total amount required to pay for the service and interest is fully paid,

and I understand that the above plan of payment, on verification of the total amount required to pay for the service, is subject to adjustment in accordance with the Canadian Forces Superannuation Regulations.

Signed at blank line on blank line

blank line(Place)blank line(Date of Election)

blank line

(Signature of Contributor)

Witnessed as to signature of contributor by:

blank lineblank lineblank line

(Name of Witness, printed in full)blank line(Signature of Witness)

PART IIElection to Repay Annuity or Pension Drawn During a Period of Elective Service(To be completed by a contributor who was in receipt of Canadian Forces Superannuation Act annuity payments or pension payments under the Defence Services Pension Act during the one-year period of continuous full-time reserve service immediately preceding deemed re-enrolment.)

  • 3 I, S.N. blank line, (Rank) blank line,

(Full names) blank line,

hereby elect, under subsection 41(4) of the Canadian Forces Superannuation Act, to repay the part of (indicate choice by placing an “X” in the appropriate box)

OR

    • (b) the pension paid to me under Part V of the Defence Services Pension Act,

during the one-year period of continuous full-time reserve service described in subsection 41(3) of the Canadian Forces Superannuation Act.

  • 4 I will make payment, in a lump sum, within 30 days after receipt of notification of the amount due.

Signed at blank line on blank line

blank line(Place)blank line(Date)

blank line

(Signature of Contributor)

Witnessed as to signature of contributor by:

blank lineblank lineblank line

(Name of Witness, printed in full)blank line(Signature of Witness)

PART IIIForwarding of Election

  • 5 I certify that the above election was (place an “X” in the appropriate box):

OR

    • (b) not forwarded to me until (date forwarded) blank line,a date subsequent to the expiration of the period required under the Canadian Forces Superannuation Act.

blank line

(Commanding Officer or person designated by the Minister)

blank lineblank lineblank line

(Date)blank line(Unit)

PART IVMedical Certificate — Belated Election(This certificate is required ONLY for an election to count service for which the contributor failed to elect within one year of becoming a contributor under the Canadian Forces Superannuation Act. The medical examination shall be made within the period beginning 90 days before and ending 90 days after this election, unless otherwise authorized by the Minister.)

  • 6 I certify that the contributor has been medically examined as to mental and physical fitness to perform duties as a member of the Canadian Forces and that the contributor (place an “X” in the appropriate box)

    • (a) is fit

OR

    • (b) is not fit

to perform duties as a member of the Canadian Forces.

blank lineblank lineblank line

(Date of Medical Examination)blank line(Signature of Medical Officer)

blank lineblank lineblank line

(Unit)blank line(Name and Appointment, printed in full)

blank line

Canadian Forces Superannuation Act

Election to Surrender Right to Pay on Retirement for Non-Contributory Regular Force Service

(This form is only for use by a member of the regular force who, at any time subsequent to the coming into force of the Canadian Forces Superannuation Act (CFSA), elects, pursuant to subsection 9(3) of the Act to surrender his right, under subsection 56(2) of Part V of the Defence Services Pension Act, as to manner of payment for prior non-contributory service in the regular force.)

PART IElection and Plan of Payment

  • 1 I, blank line Service No. blank line

    (Full given names followed by surname)

    Rank blank line Base or other unit or element

    hereby elect, pursuant to subsection 9(3) of the CFSA, to surrender my right under subsection 56(2) of Part V of the Defence Services Pension Act to defer payment for my prior service in the regular force for which I was not required to pay until the date of my retirement.

  • 2 I understand that upon the making of this election I am required to pay the same amount of contributions, without interest, for such service and I will make payment in whole or in part prior to my retirement in the following manner (choose only ONE plan of payment and indicate choice by placing X in the appropriate block):

    • (a) by lump sum payment from personal funds or DVA Re-establishment Credit; OR

    • (b) by lump sum payment in partial settlement of arrears from personal funds or DVA Re-establishment Credit in the amount of $‍blank line;

      the balance to be paid in monthly instalments of $blank line commencing on the first day of the month following the month in which this election is made; OR

    • (c) by monthly instalents of $blank line commencing on the first day of the month following the month in which this election is made.

  • 3 I further understand that:

    • (a) any instalment will continue until the amount owing is paid in full or the date of my retirement, whichever is the earlier; and

    • (b) any balance remaining to be paid at the date of my retirement must be paid in one lump sum or by instalments in accordance with Canadian Forces Superannuation Regulations.

Signed* (and forwarded) at blank line this

blank line(Place)

day of blank line, 19blank line

blank line(Date of Election)

(*Delete if not forwarded at the time of making election)

Witnessed as to signature of contributor by:

blank lineblank lineblank line

(Signature of Witness)blank line(Signature of Contributor)

PART IIForwarding of Election

  • 4 The circumstances of the forwarding of the above election having been ascertained, I am satisfied that it was (indicate by placing X in the appropriate block):

    • (a) FORWARDED to me within one month from the date of the above election; OR

    • (b) NOT FORWARDED to me until the blank line day of blank line, 19blank line a date subsequent to one month from the date of the above election.

blank line

(Commanding Officer or person Designated by the Minister)

blank lineblank lineblank line

(Date)blank line(Base or other unit or element)

CFSA 102

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Canadian Forces Superannuation Act

Election to Surrender Annuity or Annual Allowance Under Public Service Superannuation Act or Royal Canadian Mounted Police Superannuation Act

PART IElection and Plan of Payment

  • 1 I, blank line Service No. blank line

    blank line(Full given names followed by surname)

    Rank blank line Base or other unit or element blank line

    hereby elect pursuant to subsection 46(2) of the Canadian Forces Superannuation Act (CFSA), to surrender my right to an annuity or annual allowance under (indicate by placing X in the appropriate block):

    in respect of my pensionable service as described in the said subsection; and I understand that in so electing I, or any person to whom any benefit might otherwise have become payable under the above Act, in respect of such service, will cease to be entitled to any benefit thereunder.

  • 2 I will pay any amount remaining unpaid for the above service in the following manner (choose only ONE plan of payment and indicate choice by placing X in the appropriate block);

    • (a) by lump sum payment from personal funds or DVA Re-establishment Credit; OR

    • (b) by lump sum payment in partial settlement of arrears from personal funds or DVA Re-establishment Credit in the amount of $blank line, the balance to be paid in monthly instalments of $blank line commencing the first day of the month following the month in which this election is made and continuing until the total arrears of contributions and interest are fully paid; OR

    • (c) by monthly instalments of $blank line commencing the first day of the month following the month in which this election is made and continuing until the total arrears of ons and interest are fully paid;

and I understand that the above plan of payment, upon verification of the total arrears of contributions, is subject to adjustment in accordance with the Canadian Forces Superannuation Regulations.

Signed* (and forwarded) at blank line this blank line

blank line(Place)

day of blank line, 19blank line

blank line(Date of Election)

(*Delete if not forwarded at the time of making election)

Witnessed as to signature of contributor by:

blank lineblank lineblank line

(Signature of Witness)blank line(Signature of Contributor)

(A further election on Form CFSA 100 (Election to Pay for Prior Pensionable Service) will be required, within the time prescribed by the CFSA, for any other prior elective pensionable service that the contributor wishes to count.)

PART IIForwarding of Election

  • 3 The circumstances of the forwarding of the above election having been ascertained, I am satisfied that it was (indicate by placing X in the appropriate block):

    • (a) FORWARDED to me within one year of the elector having become a contributor under the CFSA; OR

    • (b) NOT FORWARDED to me until the blank line day of blank line, 19blank line a date subsequent to one year of the elector having become a contributor under the CFSA.

blank line

(Commanding Officer or person designated by the Minister)

blank lineblank lineblank line

blank line(Date)blank line(Base or other unit or element)

CFSA 103

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Canadian Forces Superannuation Act

Application for Reduction of Instalments

(This form is for use by a contributor who, pursuant to subsection 14(4) of the Canadian Forces Superannuation Regulations, applies for a reduction in the amount of his monthly instalments in respect of an election made under the Canadian Forces Superannuation Act (CFSA) to pay for elective pensionable service.)

PART IApplication for Reduction

  • 1 I, blank line Service No. blank line

    blank line(Full given names followed by surname)

    Rank blank line Base or other unit or element blank line

    hereby apply to reduce my instalments to pay for prior elective pensionable service, in respect of my election under the CFSA from $blank line to $blank line monthly.

  • 2 I certify that the reason for this application is that undue financial hardship, which was unforeseen by me at the time of making my election, will be caused to me if I am required to continue to pay at my present instalment rate and I submit the following particulars to substantiate my application (use attachments if required):

  • 3 I attach the following material to support this application:

    • (a) a statement from my accounting officer which reflects my current monthly recurring credits and debits;

    • (b) a detailed statement of all my financial obligations, including accommodation, food, family medical expenses, sundry items, etc.; and

    • (c) a detailed statement of any income from sources other than my pay and allowances.

Signed atblank line this blank line day of blank line, 19blank line

blank line(Place)blank line(Date of Application)

Witnessed as to signature of contributor by:

blank lineblank lineblank line

(Signature of Witness)blank line(Signature of Contributor)

PART IIReceipt of Application

  • 4 The foregoing application was received by me on blank line day of blank line, 19blank line

blank line

blank line(Commanding Officer or person designated by the Minister)

blank lineblank lineblank line

blank line(Date)blank line(Base or other unit or element)

PART IIIMedical Certificate

(The medical examination shall be made within a period of 90 days immediately prior to or after the application unless otherwise authorized by the Minister.)

  • 5 I certify that the contributor has been medically examined as to his mental and physical fitness to perform his duties as a member of the forces, and that he has (indicate by placing X in the appropriate block):

    • (a) PASSED such medical examination; OR

    • (b) NOT PASSED such medical examination.

blank lineblank lineblank line

blank line(Date of Medical Examination)blank line(Signature of Medical Officer or Civilian Practitioner)

blank lineblank lineblank line

blank line(Base or other unit or element)blank line(Name and appointment to be printed in full)

CFSA 105

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FORM CFSA 106Canadian Forces Superannuation Act

Surrender of Right to Count Pensionable Service Without Pay

(To be completed by a contributor who does not wish to contribute in respect of the portion of a period of service in excess of 3 months in respect of which no pay was authorized (e.g., leave without pay), pursuant to s. 6.1(1) of the Canadian Forces Superannuation Act and s. 11(2.2) of the Canadian Forces Superannuation Regulations. The election must be signed within 90 days after the end of such service or within 90 days after the day on which the contributor is required to resume making contributions under the Act, whichever is later. A separate form must be completed for each period in excess of 3 months in respect of which no pay was authorized.)

PART ISurrender of Right

  • 1 I, S.N. blank line, (rank) blank line,

(full names) blank line,

hereby surrender my right to count as pensionable service the period from blank line 

blank line(day)  (month)  (year)

to blank line,

blank line(day)  (month)  (year)

both dates inclusive, which is the portion of a period of service that is in excess of 3 months and in respect of which no pay was authorized to be paid to me because (state reasons for which no pay was authorized):

blank line

blank line

blank line

  • 2 The entire period of service for which no pay was authorized, including the first 3 months for which contributions must be paid, is the period from blank line to blank line .

blank line(day)  (month)  (year)blank line(day)  (month)  (year)

  • 3 I understand that the period of service described in section 1, which is the portion in excess of 3 months, will NOT be counted as pensionable service for computing any benefit under the Canadian Forces Superannuation Act.

Signed atblank line on blank line

blank line(place)blank line(date)

blank line

(signature of contributor)

Witnessed as to signature of contributor by:

blank lineblank lineblank line

(name of witness, printed in full)blank line(signature of witness)

PART IIForwarding of Election

  • 4 I certify that the above election was (place an “X” in the appropriate box):

    • (a) FORWARDED to me within the period prescribed for the making of this election.

OR

    • (b) NOT FORWARDED to me until (date forwarded) blank line, a date subsequent to the expiration of the period prescribed for the making of this election.

blank line

(Commanding Officer or other person designated by the Minister)

blank lineblank lineblank line

blank line(date)blank line(unit)

blank line

Canadian Forces Superannuation Act

Revocation of Election to Pay for Prior Pensionable Service

(This form is for use by a contributor who, pursuant to subsection 8(4) of the Canadian Forces Superannuation Act and section 13 of the Canadian Forces Superannuation Regulations, requests revocation, in whole or in part, of an election to pay for service made under that Act.)

PART IRequest for Revocation

  • 1 I, blank lineblank lineService No. blank line

    (Full given names followed by surname)

Rankblank lineBase or other unit or elementblank line hereby request that my election to pay for prior elective pensionable service, made under the Canadian Forces Superannuation Act, be REVOKED as to (indicate by placing X in appropriate block):

  • (a) ALL MY PRIOR PENSIONABLE SERVICE; OR

  • (b) PART ONLY OF MY PRIOR PENSIONABLE SERVICE, namely

(specify type and period of service for which revocation is requested):

blank line

blank line

blank line

  • 2 I hereby certify that the reason for this request is as follows (indicate by placing X in the appropriate block):

    • (a) I received erroneous information, or misleading information in writing, from a member of the regular force or a person employed in the Public Service who normally gives information as to the amount required to be paid under the Canadian Forces Superannuation Act for service, and in making the election, I honestly acted upon that information, OR

    • (b) Undue financial hardship, unforeseen by me at the time of making the election, will be caused to me if I am required to continue to pay for the above period of service.

  • 3 I submit the following particulars to substantiate my request (use attachments if needed):

  • 4 I understand that, if my request is approved by the Minister of National Defence, I shall be required to pay Her Majesty the amount in respect of any benefit accruing to me during the subsistence of my election, as a consequence of my having elected, as the Minister determines in accordance with the Canadian Forces Superannuation Regulations.

Signed* (and forwarded) at blank line this blank line

blank line(Place)

day of blank line, 19blank line

blank line(Date of Request)

(*Delete if not forwarded at time of making request)

Witnessed as to signature of contributor by

blank lineblank lineblank line

(Signature of Witness)blank line(Signature of Contributor)

PART IIForwarding of Request

  • 5 The circumstances of the forwarding of the above request having been ascertained, I am satisfied that it was (indicate by placing X in the appropriate block):

    • (a) FORWARDED to me within thirty days of the making of this request; OR

    • (b) NOT FORWARDED to me until theblank lineday ofblank line, 19blank line a date subsequent to thirty days of the making of this request.

blank line

(Commanding Officer or person designated by the Minister)

blank lineblank lineblank line

blank line(Date)blank line(Base or other unit or element)

PART III

  • 6 I hereby grant the above request effective the day ofblank line, 19blank line

blank lineblank lineblank line

(Date)blank line(Minister of National Defence)

CFSA 107

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CFSA 108 [Repealed, SOR/92-717, s. 7]

  • SOR/92-717, ss. 7, 10
  • SOR/95-569, s. 4
  • SOR/95-570, ss. 3, 5, 6(F) to 12(F)
  • SOR/2001-76, s. 8
Date modified: