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Pension Benefits Standards Regulations, 1985 (SOR/87-19)

Regulations are current to 2024-02-20 and last amended on 2017-06-23. Previous Versions

SCHEDULE V(Sections 20, 20.1, 20.2 and 20.3)

FORM 1Attestation Regarding Withdrawal Based on Financial Hardship

  • 1 To: (insert name of financial institution)blank line

  • 2 List of applicable federally regulated locked-in plans: (Please identify any locked-in registered retirement savings plan, life income fund, restricted locked-in savings plan or restricted life income fund that is held by the financial institution identified above and from which you intend to withdraw or transfer funds.)

    (a) blank line

    (b) blank line

    (c) blank line

  • 3 Attestation

    I, (insert name) blank line, of (insert address)blank line, in the city of blank line, in the province of blank line, attest to the following:

    I own the federally regulated locked-in plan(s) identified in item 2. On the day on which I sign this Attestation (choose all that apply):

    (A) Withdrawal for Expenditures on Medical or Disability-related Treatment or Adaptive Technology
    (a) blank lineMy total expected income for the calendar year, determined in accordance with the Income Tax Act (excluding the withdrawal referred to in line G below and any withdrawal made under paragraph 20(1)(d), 20.1(1)(m), 20.2(1)(e) or 20.3(1)(m) of the Pension Benefits Standards Regulations, 1985 within the last 30 days before this application) is $blank line;
    (b) blank lineI submit a letter signed by a physician certifying that medical or disability-related treatment or adaptive technology is required;
    (c) blank lineI expect to make expenditures on the medical or disability-related treatment or adaptive technology specified in the physician’s certificate in the amount of $blank line, which is greater than 20% of my total expected income for the calendar year;
    (d) blank lineI have not made any other withdrawal, other than within the last 30 days before this application, during the calendar year under paragraph 20(1)(d), 20.1(1)(m), 20.2(1)(e) or 20.3(1)(m) of the Pension Benefits Standards Regulations, 1985; and
    (B) Withdrawal Based on Low Income
    blank lineMy total expected income for the calendar year, determined in accordance with the Income Tax Act (excluding the withdrawal referred to in line G below and any withdrawal made under paragraph 20(1)(d), 20.1(1)(m), 20.2(1)(e) or 20.3(1)(m) of the Pension Benefits Standards Regulations, 1985 within the last 30 days before this application), is less than three quarters of the Year’s Maximum Pensionable Earnings as defined in the Pension Benefits Standards Act, 1985.
  • 4 Amount Sought for Withdrawal

    AExpected income in the calendar year determined in accordance with the Income Tax Act.$ blank line
    BTotal financial hardship withdrawals made during the calendar year from all federally regulated locked-in registered retirement savings plans, life income funds, restricted life income funds and restricted locked-in savings plans.$ blank line
    B(i): total low income component of B is$ blank line
    B(ii): total medical and disability-related income component of B is$ blank line
    C50% of the Year’s Maximum Pensionable Earnings as defined in the Pension Benefits Standards Act, 1985.$ blank line
    Calculation of Low Income Component of Withdrawal
    (To be completed only if seeking withdrawal under this component.)
    DLow income withdrawal component.
    D(i)A - B$ blank line
    D(ii)66.6% of D(i)$ blank line
    D(iii)C - D(ii)$ blank line
    D(iv)D(iii) - B(i)$ blank line
    Enter amount from D(iv) if greater than zero, otherwise enter “0”$ blank line
    Calculation of Medical and Disability-Related Component of Withdrawal
    (To be completed only if seeking withdrawal under this component.)
    EE(i) Total expected medical and disability-related expenditures in the calendar year that a medical doctor certifies are required.$ blank line
    E(ii)A - B$ blank line
    E(iii)20% of E(ii)$ blank line
    E(iv)If E(i) is greater than or equal to E(iii), enter E(i), otherwise enter “0”$ blank line
    E(v) Total expected medical and disability-related expenditures for which unlocking is being sought.Enter the lesser of E(iv) and C$ blank line
    Enter amount from E(v)$ blank line
    Calculation of Financial Hardship Withdrawal
    FTotal amount eligible for financial hardship withdrawal.
    F(i)D + E$ blank line
    F(ii)C - B$ blank line
    F(iii)Enter the lesser of F(i) and F(ii)$ blank line
    Enter amount from F(iii)$ blank line
    GTotal amount sought for withdrawal.
    Enter F or a lesser amount$ blank line
  • 5 Signatures

    Sworn before me, on the blank line day of

    blank line, 20 blank line

    at blank line, in the province of

    blank line.

    Signature of applicant blank line

    blank line

    A notary public, commissioner or other person authorized to take affidavits

FORM 2Attestation(s) Regarding Spouse/Common-Law Partner

  • 1 To: (insert name of financial institution)blank line

  • 2 List of applicable federally regulated locked-in plans: (Please identify any locked-in registered retirement savings plan, life income fund, restricted locked-in savings plan or restricted life income fund that is held by the financial institution identified above and from which you intend to withdraw or transfer funds.)

    (a) blank line

    (b) blank line

    (c) blank line

  • 3 Attestation of applicant

    I, (insert name) blank line, of (insert address)blank line, in the city of blank line, in the province of blank line, attest to the following:

    I own the federally regulated locked-in plan(s) identified in item 2. I intend to withdraw or transfer $ blank line from the plan(s). On the day on which I sign this Attestation (check one):

    (a) blank lineI do not have a spouse or common-law partner, as defined in section 2 of the Pension Benefits Standards Act, 1985;
    (b) blank lineI have a spouse or common-law partner, as defined in section 2 of the Pension Benefits Standards Act, 1985, and my spouse or common-law partner consents to the withdrawal of the amount specified above from the locked-in plan(s) identified in item 2. (If you check this box, your spouse or common-law partner must complete the Attestation of Spouse or Common-law Partner, in item 6 below.)
  • 4 Acknowledgements

    I understand that when funds are withdrawn or transferred from any federally regulated locked-in plan, the funds may lose the creditor protection provided by the Pension Benefits Standards Act, 1985 and the Pension Benefits Standards Regulations, 1985.

    I understand that when funds are withdrawn or transferred from any federally regulated locked-in plan, the funds may be taxable under the Income Tax Act or other legislation.

    I understand that I may need to seek professional advice about the financial and legal implications of such a withdrawal or transfer.

  • 5 Signatures

    Sworn before me, on the blank line day of

    blank line, 20 blank line

    at blank line, in the province of

    blank line.

    Signature of applicant blank line

    blank line

    A notary public, commissioner or other person authorized to take affidavits

  • 6 Attestation of Spouse or Common-law Partner

    I, (insert name) blank line, of (insert address)blank line, in the city of blank line, in the Province of blank line, attest to the following:

    I am the spouse or common-law partner of the owner of the locked-in plan(s) identified in item 2.

    I understand that

    • (a) the applicant intends to withdraw or transfer funds from the federally regulated locked-in plans identified in item 2, which withdrawal or transfer is not permitted under the Pension Benefits Standards Act, 1985 unless the applicant obtains my consent;

    • (b) as long as these funds are kept in that federally regulated locked-in plan, I may have a right to a share of these funds if there is a breakdown in our relationship or if the owner dies;

    • (c) if any funds are withdrawn or transferred from that federally regulated locked-in plan, I may lose any right that I have to a share of the funds withdrawn or transferred;

    • (d) when funds are withdrawn or transferred from any federally regulated locked-in plan the funds may lose the creditor protection provided by the Pension Benefits Standards Act, 1985 and the Pension Benefits Standards Regulations, 1985;

    • (e) when funds are withdrawn or transferred from any federally regulated locked-in plan the funds may be taxable under the Income Tax Act or other legislation; and

    • (f) I may need to seek professional advice about the financial and legal implications of such a withdrawal or transfer.

  • 7 Consent of Spouse or Common-law Partner

    I consent to the withdrawal or transfer specified in item 3.

  • 8 Signatures

    Sworn before me, on the blank line day of

    blank line, 20 blank line

    at blank line, in the province of

    blank line.

    Signature of spouse or common-law partner blank line

    blank line

    A notary public, commissioner or other person authorized to take affidavits

FORM 3Attestation of Total Amount Held in Federally Regulated Locked-In Plans

  • 1 To: (insert name of financial institution)blank line

  • 2 List of applicable federally regulated locked-in plans: (Please identify all locked-in registered retirement savings plan, life income fund, restricted locked-in savings plan or restricted life income fund which you own including any that are held by financial institutions other than the one identified above.)

    (a) blank line

    (b) blank line

    (c) blank line

  • 3 Attestation

    I, (insert name) blank line, of (insert address)blank line, in the city of blank line, in the province of blank line, attest to the following:

    I own the federally regulated locked-in plans identified in item 2. On the day on which I sign this Attestation the total value of all of the locked-in plan(s) identified in item 2 is $blank line.

    On the day on which I sign this Attestation the total value of all of the locked-in plan(s) identified in item 2 is $blank line.

    The total value of all locked-in plan(s) identified in item 2 is less than 50% of the Year’s Maximum Pensionable Earnings as defined in the Pension Benefits Standards Act, 1985.

  • 4 Signatures

    Sworn before me, on the blank line day of

    blank line, 20 blank line

    at blank line, in the province of

    blank line.

    Signature of applicant blank line

    blank line

    A notary public, commissioner or other person authorized to take affidavits

  • SOR/2008-144, s. 8
  • SOR/2015-60, s. 32
 

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