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

[Repealed, SOR/95-171, s. 6]

• 1 Name, address and telephone number of the administrator.

• 2 Name and address of the pension fund custodian or trustee together with any applicable policy or account number.

• 3 Name and address of the external auditor.

• 4 Total membership in the plan at plan year end.

• 5 List of all members of a board of trustees or pension committee of the plan.

• 1 Are all of the benefits provided by an insured plan or by a pension plan in respect of which an annuity contract has been issued by the Government of Canada?

  Yes No

• 2 Are all of the pension plan’s assets held in an unallocated general fund of a person authorized to carry on a life insurance business in Canada?

  Yes No

(If the answer to Question 1 and 2 is “No”, complete the following.)

• 3 As at the end of the last plan year, had the administrator established a written statement of investment policies and procedures in accordance with subsection 7.1(1) to the Pension Benefits Standards Regulations, 1985?

  Yes No

• 4 If a statement of investment policies and procedures had been established as at the end of the plan year preceding the last plan year, did the administrator review it during the last plan year?

  Yes No

• 5 If a statement of investment policies and procedures had been established as at the end of the plan year preceding the last plan year, was the statement amended during the last plan year?

  Yes No

• 6 If a statement of investment policies and procedures was established or amended during the last plan year, were the pension council, if one exists, and the actuary to the plan, if the pension plan is a defined benefit plan, given a copy of the statement or amendments in accordance with subsection 7.1(3) or 7.2(2) of the Pension Benefits Standards Regulations, 1985?

  Yes No

• 7 During the last plan year, were the moneys of the pension fund invested in accordance with section 6 of the Pension Benefits Standards Regulations, 1985?

  Yes No

Certification

I hereby certify that, to the best of my knowledge and belief, the information entered on this Investment Information Return, and any other information that has been requested by the Superintendent of Financial Institutions and is attached to this Return, is true and correct.

Administrator’s Signature

Name(s) (Use block letters)

• (If the administrator is a board of trustees or other similar body, all trustees or members of the body must sign)

Date:

• 1 Applicant

  I, , am a (member, former member, survivor) of the registered pension plan known as

  and I apply to

• 2 Transfer or Purchase (check one)

  • (a)  

    transfer my pension benefit credit to a locked-in registered retirement savings plan of the kind described in section 20 of the Pension Benefits Standards Regulations, 1985;
  • (b)  

    transfer my pension benefit credit to a life income fund of the kind described in section 20.1 of the Pension Benefits Standards Regulations, 1985;
  • (c)  

    transfer my pension benefit credit to a restricted life income fund of the kind described in section 20.3 of the Pension Benefits Standards Regulations, 1985;
  • (d)  

    use my pension benefit credit to purchase an immediate life annuity of the kind described in section 21 of the Pension Benefits Standards Regulations, 1985;
  • (e)  

    use my pension benefit credit to purchase a deferred life annuity of the kind described in section 21 of the Pension Benefits Standards Regulations, 1985;
  • (f)  

    transfer my pension benefit credit to a pension plan of which I am currently a member, which is known as ; or
  • (g)  

    transfer my pension benefit credit to a PRPP.

• 3 Signatures

  Signature of member (or former member or survivor)

  Name of member (or former member or survivor)

  Signature of witness

  Name of witness

  Address of witness

  Signed at on , 20.

• 4 Confirmation of the request received by the financial institution for (check one)

  • (a)  

    a transfer of the funds to a locked-in registered retirement savings plan of the kind described in section 20 of the Pension Benefits Standards Regulations, 1985;
  • (b)  

    a transfer of the funds to a life income fund of the kind described in section 20.1 of the Pension Benefits Standards Regulations, 1985;
  • (c)  

    a transfer of the funds to a restricted life income fund of the kind described in section 20.3 of the Pension Benefits Standards Regulations, 1985;
  • (d)  

    the use of the funds to purchase a deferred life annuity of the kind described in section 21 of the Pension Benefits Standards Regulations, 1985; or
  • (e)  

    the use of the funds to purchase an immediate life annuity of the kind described in section 21 of the Pension Benefits Standards Regulations, 1985, the funds of which shall be only used to purchase another immediate life annuity that meets the requirements of those Regulations.

• 5 Signatures

  Signature of applicant

  Name of applicant

  Signature of officer of financial institution

  Name of financial institution

  Signed at on , 20.

I, , hereby certify that I am the spouse or common-law partner as defined by the Pension Benefits Standards Act, 1985, of .

I understand that my spouse or common-law partner has elected to transfer their pension benefit credit and that my written consent is required to enable my spouse or common-law partner to do so.

I understand that

• (a) transferring the pension benefit credit will allow my spouse or common-law partner to manage their own pension fund and will allow flexibility in determining the amount that will be paid to my spouse or common-law partner in each calendar year;

• (b) the transferred funds may be used to purchase a life annuity at a later date, but there is no requirement that the funds be used to purchase a life annuity;

• (c) if the transferred funds are used to purchase a life annuity, the life annuity must be in the joint and survivor form unless I waive my entitlements by signing a separate waiver form within 90 days before the day on which the annuity payments begin.

I further understand that transferring the pension benefit credit to a retirement savings plan of the prescribed kind will allow my spouse or common-law partner to withdraw some of the funds each year, subject to any minimum and maximum withdrawal limits. I understand, however, that the amount of pension income or survivor benefit available to me in later years may be significantly reduced if

• (a) my spouse or common-law partner elects to withdraw the maximum amount permitted each year; or

• (b) the investment performance is poor.

Nevertheless, I consent to the transfer of the pension benefit credit to a retirement savings plan of the prescribed kind and certify that

• (a) I have read this form and understand it;

• (b) neither my spouse or common-law partner nor anyone else has put any pressure on me to sign this form;

• (c) I realize that

  • (i) this form only gives a general description of the legal rights I have under the Pension Benefits Standards Act, 1985 and the Pension Benefits Standards Regulations, 1985, and

  • (ii) if I wish to understand exactly what my legal rights are I must read the Pension Benefits Standards Act, 1985 and the Pension Benefits Standards Regulations,1985 or seek legal advice; and

• (d) I realize that I am entitled to keep a copy of this consent form.

To consent to the transfer, I sign this consent form at on , 20.

Name and registration number of pension plan of my spouse or common-law partner

Signature of spouse or common-law partner

Address of spouse or common-law partner

(home telephone number)

(work telephone number)

STATEMENT OF WITNESS

I certify that

• (a) My full name is

• (b) My address is

• (c) I witnessed sign this waiver.

Signature of witness

(home telephone number)

(work telephone number)

I, , hereby certify that I, am (a) the spouse or (b) the common-law partner, as defined in section 2 of the Pension Benefits Standards Act, 1985 of , a (member) (former member) of the pension plan known as .

Under the terms of that pension plan,

• (a) the amount of pension benefit payable to my spouse or common-law partner as a (member) (former member) is $ per (period), and

• (b) the amount of the pension benefit payable to me on the death of my spouse or common-law partner is $ per (period), this amount being not less than 60 per cent of the pension benefit payable to my spouse or common-law partner in accordance with subsection 22(2) of the Pension Benefits Standards Act, 1985.

Based on the above, and in accordance with subsection 22(5) of the Pension Benefits Standards Act, 1985, I hereby agree to waive:

		Check one
1	my entitlement to any pension benefit payable to me on the death of my spouse or common-law partner, or
2	a portion of the pension benefit payable to me on the death of my spouse or common-law partner so that my pension benefit is $ per (period), this amount being less than the minimum 60 per cent of the pension benefit payable to my spouse or common-law partner to which I would otherwise be entitled

To:	The Superintendent of Financial Institutions, Ottawa.
Name of Administrator
Mailing Address in Canada
Pursuant to section 32 of the Pension Benefits Standards Act, 1985, notice of objection is hereby given to the action of the Superintendent of Financial Institutions in (refusing registration) (revoking registration and cancelling the certificate of registration) of the pension plan known as
as evidenced by the Superintendent’s notification dated the day of , 19.
The reasons for objection and the facts relevant thereto are as follows:
		Signature
Date		Title or Position
NOTE:
1	This form is for the use of an administrator who, pursuant to section 32(1) of the Act, wishes to make a formal objection to the action of the Superintendent of Financial Institutions in refusing registration or revoking the registration and cancelling the certificate of registration of a pension plan.
2	TWO copies of the objection are to be sent by REGISTERED MAIL to the Superintendent of Financial Institutions, Office of the Superintendent of Financial Institutions, Ottawa, K1A 0H2, Canada. For the notice of objection to have effect, the envelope containing the objection must be postmarked within 60 days after the date that the Superintendent of Financial Institutions mailed the notification that registration had been refused or that registration had been revoked and the certificate of registration cancelled, as the case may be.
3	The NOTICE OF OBJECTION must be signed by the administrator.

In Re the Pension Benefits Standards Act, 1985

BETWEEN

Appellant

-and-

Respondent

NOTICE OF APPEAL

NOTICE OF APPEAL is hereby given from the decision of the Superintendent of Financial Institutions to (refuse) (revoke) registration of the pension plan known as

as evidenced by the notifications of the Superintendent dated the day of , 19, and the day of , 19.

A Statement of Facts

(Insert a brief statement of the facts, including the date and a brief résumé of the particulars of the application for registration or the circumstances surrounding the revocation of the registration of the pension plan.)

B The statutory provisions upon which the Appellant relies and the Reasons that the Appellant intends to submit:

C Name and Address of Appellant’s Solicitor (if any):

Dated at this day of , 19 .

(Appellant)