Interim Cost Certificate Form - Alberta Treasury Board And Finance

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OFFICE USE ONLY
R
S
ECEIVED
TAMP
Entered
Superintendent of Pensions
#402, 9515 – 107
Street
th
Reviewed
Edmonton, AB T5K 2C3
Phone: (780) 427-8322 Fax: (780) 422-4283
INTERIM COST CERTIFICATE
A
R
D
: ______ /______/_______
A
CTUARIAL
EVIEW
ATE
MUST COINCIDE WITH THE
CTUARIAL
CRA N
:
UMBER
YYYY
MM
DD
R
D
F
R
EVIEW
ATE OF THE LAST
ULL
EVIEW FILED
C
S
D
:
/
/
(YYYY-MM-DD) –Effective Date of the event requiring this Interim Cost Certificate
ERTIFICATE
TART
ATE
O
N
P
:
FFICIAL
AME OF THE
LAN
O
C
S
C
NLY
OMPLETE THE
ECTIONS THAT HAVE
HANGED
N
A
(C
S
) C
A
A
E
D
I
C
C
ORMAL
CTUARIAL
URRENT
ERVICE
OST
S
T THE
FFECTIVE
ATE OF THIS
NTERIM
OST
ERTIFICATE
EMPLOYER COST
MEMBER COST
E
N
A
C
STIMATED
ORMAL
CTUARIAL
OST FOR THE
$
$
Y
F
C
S
D
EAR
OLLOWING
ERTIFICATE
TART
ATE
________ %
M
C
OF
EMBER
ONTRIBUTIONS OR
________ %
C
P
OF
OVERED
AYROLL
R
N
A
C
ULE FOR HOW THE
ORMAL
CTUARIAL
OST
________ %
C
P
OF
OVERED
AYROLL
IS CALCULATED
O
(describe):
O
(describe):
THER
THER
NEW U
L
(
) C
E
D
I
C
C
NFUNDED
IABILITY
IES
REATED AT THE
FFECTIVE
ATE OF THIS
NTERIM
OST
ERTIFICATE
D
E
ANNUAL S
P
E
A
ATE
STABLISHED
PECIAL
AYMENT
ND OF
MORTIZATION
A
U
L
MOUNT OF
NFUNDED
IABILITY
(YYYY-MM-DD)
(
)
(YYYY-MM-DD)
MONTHLY AMORTIZATION SCHEDULE
$
$
/
/
/
/
$
$
/
/
/
/
NEW S
D
(
) C
E
D
I
C
C
OLVENCY
EFICIENCY
IES
REATED AT THE
FFECTIVE
ATE OF THIS
NTERIM
OST
ERTIFICATE
D
E
ANNUAL S
P
E
A
ATE
STABLISHED
PECIAL
AYMENT
ND OF
MORTIZATION
A
S
D
MOUNT OF
OLVENCY
EFICIENCY
(YYYY-MM-DD)
(
)
(YYYY-MM-DD)
MONTHLY AMORTIZATION SCHEDULE
$
$
/
/
/
/
$
$
/
/
/
/
Revised Information for Specified Multi-Employer Pension Plans (SMEPPs) Only
N
A
C
$
U
L
P
: $
S
D
P
: $_____
:
________/hour
______/hour
/hour
ORMAL
CTUARIAL
OST
NFUNDED
IABILITY
AYMENTS
OLVENCY
EFICIENCY
AYMENTS
I confirm that this interim cost certificate has been prepared in accordance with the Employment Pension Plans Act and
Regulation. It is not intended to satisfy the reporting requirements of actuarial valuations for funding purposes under either the
Income Tax Act (Canada) or the Practice-Specific Standards for Pension Plans as approved by the Canadian Institute of
Actuaries.
A
’
S
:
D
:
/
/
CTUARY
S
IGNATURE
ATE
N
& T
(
):
AME
ITLE
PRINTED
C
& A
:
OMPANY
DDRESS
Note: Information Collected on this form will become subject to the Freedom of Information and Protection of Privacy
Act and will be managed in accordance with that Act. If you have any questions about the collection, use or
disclosure of this information, please contact Alberta Finance at (780) 427-8322.
FSRP0020A - December 2011

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