Pension Benefits Standards Regulations, 1985
SCHEDULE IV
FORM 1(Subsection 23(2) and paragraph 23.2(a))Statement To Be Provided to a Retiring Member
Statement date 
Member’s name Date of birth
Spouse’s or common-law partner’s name Date of birth
Designated beneficiary
Date employment began
Date credited service began
Date pensionable age reached
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 $
Solvency ratio
Formula, if any, for indexing the pension benefit
FORM 2(Subsection 23(3))Statement To Be Provided if a Member Ceases To Be a Member of the Plan for Any Reason Other than the Termination of the Whole or Part of the Plan or Retirement
Statement date
Member’s name Date of birth
Spouse’s or common-law partner’s name Date of birth
Designated beneficiary
Date employment began
Date credited service began
Date pensionable age reached
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 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
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
Portability options available (transfer to another pension plan, a locked-in registered retirement savings plan, a life income fund or restricted life income fund, or purchase of an immediate or deferred life annuity)
FORM 2.1(Subsection 23.4(1))Statement To Be Provided Within 30 Days After the Termination of the Whole of the Plan
Statement date
Plan termination date
Member’s or former member’s name Date of birth
Spouse’s or common-law partner’s name Date of birth
Designated beneficiary
Each member, former member and the spouse or common-law partner of each member or former member may examine, at the plan administrator’s offices, or order photocopies of, on condition of payment of any reasonable fee that the administrator may fix, all documents that have been filed with the Superintendent under subsection 10(1) or 10.1(1) or section 12 of the Pension Benefits Standards Act, 1985 or any regulations made under paragraph 39(i) of that Act.
Pension benefits will continue to be paid to retirees as they fall due.
Other pension benefits cannot be distributed until the termination report is approved by the Superintendent.
FORM 2.2(Subsection 23.4(2))Statement To Be Provided Within 120 Days After the Termination of the Whole of the Plan
Statement date
Member’s or former member’s name Date of birth
Spouse’s or common-law partner’s name Date of birth
Designated beneficiary
Date employment began
Date credited service began
Date pensionable age reached
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 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
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
Portability options available (transfer to another pension plan, a locked-in registered retirement savings plan, a life income fund or restricted life income fund, or purchase of an immediate or deferred life annuity)
The member or former member must give notice of the transfer option that they have chosen.
A description of any adjustments to benefits and the reasons for these adjustments
FORM 3(Subsection 23(4))Statement To Be Provided when a Member or Former Member Dies
Statement date
Member’s or former member’s name Date of birth
Spouse’s or common-law partner’s name Date of birth
Designated beneficiary
Date employment began
Date credited service began
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 or former 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
Schedule of transfer payments (if solvency ratio is less than 1)
Formula, if any, for indexing benefit or for calculating the pension benefit credit
Portability options available (transfer to another pension plan, a locked-in registered retirement savings plan, a life income fund or restricted life income fund, or purchase of an immediate or deferred life annuity)
FORM 4
[Repealed, SOR/2015-60, s. 29]
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 5.2(Section 23.3)Spouse’s or Common-Law Partner’s Consent to the Election To Receive a Variable Benefit from a Defined Contribution Provision
I, , hereby certify that I am the spouse or the common-law partner, as defined in the Pension Benefits Standards Act, 1985, of .
I understand that my spouse or common-law partner has elected to receive a variable benefit directly from the pension plan, and that my written consent is required to enable my spouse or common-law partner to do so.
I understand that
(a) electing to receive a variable benefit directly from the pension plan will allow my spouse or common-law partner to manage his or her own pension fund and will allow some flexibility in determining the amount that will be paid as a variable benefit in each calendar year;
(b) the remaining funds may be used to purchase a life annuity at a later date, but there is no requirement that the remaining funds be used to purchase a life annuity;
(c) if the remaining funds are used to purchase a life annuity, the life annuity must be joint unless I waive my entitlements by signing a separate waiver form within 90 days before the day on which the annuity payments begin; and
(d) a variable benefit paid directly from the pension plan is not paid in the joint and survivor form.
I further understand that before purchasing a life annuity, the pension plan will allow my spouse or common-law partner to withdraw some of the funds each year, subject to 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 receipt of variable benefits directly from the pension plan, 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 a copy of this consent form.
To consent to the transfer, I sign this consent form at on , 20.
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.
(home telephone number)
(work telephone number)
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
- SOR/2015-60, ss. 29, 30(F), 31
- Date modified: