Statutory Declaration—In the Matter of the Canadian Forces Superannuation Act: CF-FC 2010

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

This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.

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CF-FC 2010 – Statutory Declaration—In the Matter of the Canadian Forces Superannuation Act [PDF - 402 KB]

Protected "B" when completed

Pension Number

Province of Country of

In the matter of the Canadian Forces Superannuation Act

I, (Name in Full) of Address of Relation(Complete Address)

in the county of province of

do solemnly declare:

that I am the (Relation to deceased) of the late (Name of deceased)

of Address of Deceased (Complete Address) ,

2 in the county of 2 province of

That the dependant children (include stepchildren and adopted children) now alive of the said late plan member, and their birth dates are as follows:

Live dependant child 1 Name Live dependant child 1 Date of Birth (YYYY-MM-DD)

Live dependant child 2 Name Live dependant child 2 Date of Birth (YYYY-MM-DD)

Live dependant child 3 Name Live dependant child 3 Date of Birth (YYYY-MM-DD)

Live dependant child 4 Name Live dependant child 4 Date of Birth (YYYY-MM-DD)

That I have custody and control of all the above-named dependant children, OR the following dependant children:

Live dependant child 5 Name Live dependant child 5 Date of Birth (YYYY-MM-DD)

Live dependant child 6 Name Live dependant child 6 Date of Birth (YYYY-MM-DD)

Live dependant child 7 Name Live dependant child 7 Date of Birth (YYYY-MM-DD)

Live dependant child 8 Name Live dependant child 8 Date of Birth (YYYY-MM-DD)

I make this solemn declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.

Declared before me at (City, Town or Village)

in the province of

on (YYYY-MM-DD)

Signature of Declarant

Signature of person authorized to take a Statutory Declaration. (Indicate whether a Justice of the Peace, Notary, Lawyer, Commissioner of Oaths (expiry date must be indicated), etc. and use stamp or seal)

Stamp

Signature of Person Authorized

Expiry Date (YYYY-MM-DD)

Send completed declarations to

Public Works and Government Services Canada
Government of Canada Pension Centre - Mail Facility
150 Dion Boulevard
PO Box 9500
Matane QC G4W 0H3

CF-FC 2010E (2014-11-001)

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Date modified:: 2025-06-25

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