Pension Benefits Standards Regulations, 1985

1 To: (insert name of financial institution)

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)

(b)

(c)

3 Attestation

I, (insert name) , of (insert address), in the city of , in the province of , 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)	My 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 $;
(b)	I submit a letter signed by a physician certifying that medical or disability-related treatment or adaptive technology is required;
(c)	I expect to make expenditures on the medical or disability-related treatment or adaptive technology specified in the physician’s certificate in the amount of $, which is greater than 20% of my total expected income for the calendar year;
(d)	I 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
	My 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

A	Expected income in the calendar year determined in accordance with the Income Tax Act.	$
B	Total 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.	$
	B(i): total low income component of B is	$
	B(ii): total medical and disability-related income component of B is	$
C	50% of the Year’s Maximum Pensionable Earnings as defined in the Pension Benefits Standards Act, 1985.	$
Calculation of Low Income Component of Withdrawal
(To be completed only if seeking withdrawal under this component.)
D	Low income withdrawal component.
	D(i)	A - B	$
	D(ii)	66.6% of D(i)	$
	D(iii)	C - D(ii)	$
	D(iv)	D(iii) - B(i)	$
	Enter amount from D(iv) if greater than zero, otherwise enter “0”			$
Calculation of Medical and Disability-Related Component of Withdrawal
(To be completed only if seeking withdrawal under this component.)
E	E(i) Total expected medical and disability-related expenditures in the calendar year that a medical doctor certifies are required.		$
	E(ii)	A - B	$
	E(iii)	20% of E(ii)	$
	E(iv)	If E(i) is greater than or equal to E(iii), enter E(i), otherwise enter “0”	$
	E(v) Total expected medical and disability-related expenditures for which unlocking is being sought.	Enter the lesser of E(iv) and C	$
	Enter amount from E(v)			$
Calculation of Financial Hardship Withdrawal
F	Total amount eligible for financial hardship withdrawal.
	F(i)	D + E	$
	F(ii)	C - B	$
	F(iii)	Enter the lesser of F(i) and F(ii)	$
	Enter amount from F(iii)			$
G	Total amount sought for withdrawal.
	Enter F or a lesser amount			$

5 Signatures

Sworn before me, on the day of

, 20

at , in the province of

.

Signature of applicant

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

1 To: (insert name of financial institution)

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)

(b)

(c)

3 Attestation of applicant

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

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

(a)	I do not have a spouse or common-law partner, as defined in section 2 of the Pension Benefits Standards Act, 1985;
(b)	I 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 day of

, 20

at , in the province of

.

Signature of applicant

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

6 Attestation of Spouse or Common-law Partner

I, (insert name) , of (insert address), in the city of , in the Province of , 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 day of

, 20

at , in the province of

.

Signature of spouse or common-law partner

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

1 To: (insert name of financial institution)

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)

(b)

(c)

3 Attestation

I, (insert name) , of (insert address), in the city of , in the province of , 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 $.

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 $.

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 day of

, 20

at , in the province of

.

Signature of applicant

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