Form 5 - Waiver Of 60% Joint Pension (Page 4 of 4) in pdf

Form 5 - Waiver Of 60% Joint Pension Page 4



the member or member-owner is not present while I am signing this form;



I am signing this form of my own free will without duress, coercion or compulsion of any kind; and



I realize that:

o this form only gives a general description of the legal rights I have under the Act and the regulation,

and

o if I wish to understand exactly what my legal rights are, I must read the Act and the regulation and

seek legal advice.

I hereby waive my entitlement to a joint survivor pension, and if it applies to me, I hereby also give my consent for

the member to elect an integrated pension, by signing this form in the presence of a witness.

I sign this for at

________________________

__________________________

_________________

(city/town)

(province/territory/state)

(country)

this _______________________ day of ________________________, ______________

_______________________________________________

(signature of spouse or common-law partner)

I, _________________________________________, of __________________________

(print name of witness)

_______________________________________________________________________

(print address of witness)

do witness the signature of the spouse or common-law partner who signed this form before me outside of the

presence of the member or member-owner.

_____________________________________________

(signature of witness)

Reference:

The Pension Benefits Act, Sections 23(1) – (5)

Pension Benefits Regulation, Section 3.35, Section 10.2 of Division 1, and Section 10.22 of Division 2 of Part 10

FORM 5 - Waiver of 60% Joint Pension Entitlement for Pension Plan or Locked-In Retirement Account

MAY 2012

Office of the Superintendent – Pension Commission

Form 5 - Waiver Of 60% Joint Pension Page 4