Spouse'S Consent And Waiver Form Of Post-Retirement Survivor Benefits Page 2
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1
2SECTION D: SPOUSE’S WAIVER OF 60 PER CENT POST-RETIREMENT SURVIVOR BENEFIT
1.
I understand that, in the absence of this waiver, on the death of the member, I am entitled to a pension of at least
60 per cent of the original amount of the pension payable to the member.
2.
I also understand and declare that, by signing this waiver:
a.
I am giving up my entitlement, on the death of the member, to a survivor benefit of at least 60 per cent of the
original amount of the pension payable to the member;
b.
I am permitting the member to receive a pension that does not comply with section 20(5) of The Public
Employees Pension Plan Act or with section 34 of The Pension Benefits Act, 1992; and
c.
On the death of the member, I may receive no pension or an annuity of less than 60 per cent of the
original amount of the pension payable to the member.
3.
I certify that this waiver is being signed freely and voluntarily without any compulsion on the part of the member
and outside the immediate presence of the member.
I understand that this waiver is not valid if it is signed more than 90 days before pension commencement.
4.
5.
I understand that I may revoke this waiver at any time before pension commencement by providing written notice to
the administrator of the pension plan or issuer of the contract, as the case may be.
SECTION E: CERTIFICATE OF CONSENT AND WAIVER
I certify that I am the spouse of the above named member and that I have read and understand the content of the
above sections. By signing this certificate I consent to the transfer of money from the member’s account as set out in
Section B and waive my entitlement to a survivor benefit of at least 60 per cent.
In witness whereof, I sign this certificate at _____________________________ this________ day of ___________, 20 ______
in the presence of __________________________________________________________
(print or type name of Notary or Commissioner of Oaths)
of _____________________________________________________________________________
(address of Notary or Commissioner of Oaths)
Stamp area
Signature of Spouse
Signature of Notary or Commissioner of Oaths
Date Signed (day/month/year)
SECTION G: TO BE COMPLETED BY PEPP ADMINISTRATION
______________________________
_______________________
_______________________________
_________________________
Entered by Date Confirmed by Date
For more information please see our website at
or contact us at the address listed on the front of
this form.
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