Pension Benefits Standards Regulations, 1985
SCHEDULE IV
FORM 1(Subsection 23(2) and paragraph 23.2(a))Statement To Be Provided to a Member Retiring from a Plan
Statement date 
Member’s name Date of birth
Spouse’s or common-law partner’s name Date of birth
Beneficiary
Date employment commenced
Date credited service commenced
Date of attainment of pensionable age
Date of first entitlement to early retirement pension
Credited service
Additional voluntary contributions of member
(a) made during the plan year $
(b) accumulated to date of retirement $
Required contributions of member
(a) made during the plan year $
(b) accumulated to date of retirement $
Employer contributions, in respect of a defined contribution provision, if any,
(a) made during the plan year $
(b) accumulated to date of retirement $
Transfers into the pension plan
(a) lump sum amounts $
(b) benefit attributable to such transfers $
(c) service credited to such transfers
Pension benefit payable to the member
(a) attributable to the benefit formula $
(b) attributable to additional voluntary contributions $
(c) attributable to the "50% rule” $
(d) attributable to any other lump sum amount $
(e) total pension benefit payable $
Pension benefit payable for a limited period
(a) amount $
(b) from
to
Survivor benefit: $
Formula, if any, for indexing the pension benefit
FORM 2(Subsection 23(3))Statement To Be Provided Where the Member Ceases To Be a Member of the Plan or Where All or Part of a Plan Terminates and the Member Is Entitled to a Deferred Pension Benefit
Statement date
Member’s name Date of birth
Spouse’s or common-law partner’s name Date of birth
Beneficiary
Date employment commenced
Date credited service commenced
Date of attainment of pensionable age
Date of first entitlement to early retirement pension
Credited service
Additional voluntary contributions of member
(a) made during the plan year $
(b) accumulated to date of cessation of membership $
Required contributions of member
(a) made during the plan year $
(b) accumulated to date of cessation of membership $
Employer contributions, in respect of a defined contribution provision, if any,
(a) made during the plan year $
(b) accumulated to date of cessation of membership $
Transfers into the pension plan
(a) lump sum amounts $
(b) benefit attributable to such transfers $
(c) service credited to such transfers
Pension benefit payable to the member
(a) attributable to the benefit formula $
(b) attributable to additional voluntary contributions $
(c) attributable to the “50% rule” $
(d) attributable to any other lump sum amount $
(e) total pension benefit payable $
Pension benefit payable for a limited period
(a) amount $
(b) from
to
Survivor benefit prior to early retirement
(a) total benefit $
(b) group insurance offset $
(c) net benefit $
Pension benefit credit for transfer purposes
(a) attributable to the benefit formula $
(b) attributable to additional voluntary contributions $
(c) attributable to the “50% rule” $
(d) attributable to any other lump sum amount $
(e) total pension benefit credit payable $
Solvency ratio, if less than 1
Schedule of transfer payments (if solvency ratio is less than 1)
Formula, if any, for indexing the pension benefit or for calculating the pension benefit credit
FORM 3(Subsection 23(4))Statement To Be Provided to a Member Where the Member Ceases To Be a Member and Is Not Entitled to a Deferred Pension Benefit
Statement date
Member’s name Date of birth
Date employment commenced
Date credited service commenced
Credited service
Lump sum payable to the member
(a) attributable to the member’s contributions accumulated on the interest $
(b) attributable to additional voluntary contributions $
(c) attributable to any other lump sum amount $
(d) total lump sum payable $
FORM 4(Subsection 23(5))Statement To Be Provided when a Member Dies
Statement date
Member’s name Date of birth
Date employment commenced
Date credited service commenced
Credited service
Additional voluntary contributions of member
(a) made during the plan year $
(b) accumulated to date of member’s death $
Required contributions of member
(a) made during the plan year $
(b) accumulated to date of member’s death $
Employer contributions, in respect of a defined contribution provision, if any,
(a) made during the plan year $
(b) accumulated to date of member’s death $
Transfers into the pension plan
(a) lump sum amounts $
(b) benefit attributable to such transfers $
(c) service credited to such transfers
Pension benefit credit payable to the member’s spouse or common-law partner
(a) attributable to the benefit formula $
(b) attributable to additional voluntary contributions $
(c) attributable to the “50% rule” $
(d) attributable to any other lump sum amount $
(e) total pension benefit or pension benefit credit payable $
Solvency ratio, if less than 1
Schedule of transfer payments (if solvency ratio is less than 1)
Formula, if any, for indexing benefit or for calculating the pension benefit credit
FORM 5(Paragraph 23.2(a))Statement To Be Provided to a Member to Whom a Phased Retirement Benefit Is To Be Paid and to the Member’s Spouse or Common-Law Partner
Statement date
Member’s name
Date of birth
Spouse’s or common-law partner’s name
Date of birth
Phased retirement benefit:
Phased retirement benefit payable, expressed as
(a) a percentage of the accrued pension benefit as of the date on which the agreement referred to in paragraph 16.1(3)(a) of the Act takes effect %
(b) an annual amount $
Frequency and terms of adjustment, if any, to the phased retirement benefit during the phased retirement period to reflect pension benefit accrued during that period
Formula, if any, for indexing the phased retirement benefit
Bridging benefit, payable from to , expressed as
(a) a percentage of the accrued pension benefit to date %
(b) an annual amount $
Pension benefit payable at retirement:
Formula for calculating the pension benefit payable at retirement
Formula for determining the contributions payable during the phased retirement period and the pension benefit accrual during that period and, if applicable, the proportion of part-time service for which the member will be credited
FORM 5.1(Paragraph 23.2(b))Statement To Be Provided to a Former Member to Whom a Phased Retirement Benefit Is To Be Paid and to the Former Member’s Spouse or Common-Law Partner
Statement date
Former member’s name
Date of birth
Spouse’s or common-law partner’s name
Date of birth
Phased retirement benefit:
Phased retirement benefit payable, expressed as
(a) a percentage of the pension benefit being received prior to phased retirement period %
(b) an annual amount $
Frequency and terms of adjustment, if any, to the phased retirement benefit during the phased retirement period to reflect pension benefit accrued during that period
Formula, if any, for indexing the phased retirement benefit
Bridging benefit, payable from to , expressed as
(a) a percentage of the accrued pension benefit to date %
(b) an annual amount $
Pension benefit payable at retirement:
Formula for calculating the pension benefit payable at retirement
Formula for determining the contributions payable during the phased retirement period and the pension benefit accrual during that period and, if applicable, the proportion of part-time service for which the member will be credited
NOTE: Under paragraph 16.1(4)(g) of the Pension Benefits Standards Act, 1985, if the former member is receiving an immediate pension benefit from a pension plan that provides for the payment of a phased retirement benefit, the administrator of that pension plan shall cease paying the immediate pension benefit when payment of a phased retirement benefit begins and an existing waiver of the joint and survivor pension benefit is void, except if the waiver was made under a court order or agreement relating to the distribution of property on divorce, annulment, separation or breakdown of a common-law partnership. When payment of an immediate pension benefit is to commence following the phased retirement period, a new election as to the form of that benefit may be made in accordance with subsection 22(5) of the Pension Benefits Standards Act, 1985.
FORM 6(Section 30.1)Consent of Spouse or Common-Law Partner to the Cessation of the Payment of the Joint and Survivor Pension Benefit
I, , hereby certify that I am (a) the spouse or (b) the common-law partner, as defined in subsection 2(1) of the Pension Benefits Standards Act, 1985, of , a retired former member of the pension plan known as .
Under the terms of that pension plan
(a) the amount of the joint and survivor pension benefit payable to my spouse or common-law partner as a retired former member is $ per year; and
(b) the amount of the survivor benefit that would be payable to me on the death of my spouse or common-law partner is $ per year.
I understand that:
My consent to the cessation of the payment of the joint and survivor pension benefit described in paragraph (a) is required to allow the payment of a phased retirement benefit to my spouse or common-law partner.
By giving my consent, I am no longer entitled to the survivor benefit described in paragraph (b) that currently would be payable to me on the death of my spouse or common-law partner.
If my spouse or common-law partner dies while receiving a phased retirement benefit, the survivor benefit will be payable to the person who is at that time his or her spouse or common-law partner.
A new election as to the form of the immediate pension benefit that will commence after the phased retirement period may be made when that benefit commences, in accordance with subsection 22(5) of the Pension Benefits Standards Act, 1985.
Based on the above, and in accordance with paragraph 16.1(3)(b) of the Pension Benefits Standards Act, 1985, I hereby consent to the cessation of the payment of the joint and survivor pension benefit described in paragraph (a).
Signed at on the day of , 20
Name of spouse or common-law partner
Signature of spouse or common-law partner
Name of witness (other than the former member)
Signature of witness
- SOR/2001-194, ss. 5, 6
- SOR/2009-100, ss. 3, 4
- Date modified: