Form 4 - Spouse'S Waiver Of Beneficiary Right To Benefits In A Pension Plan, Locked-In Retirement Account, Life Income Fund Or Annuity Before Payments Start

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(sections 74 (11), 76, 83 (3) (b) (ii) (A), 106 (2) (b) (i), and 125 (2) (b) (i))

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HEN TO USE THIS FORM

Form 4 is used when

 a member of a pension plan who has a spouse wishes to designate a beneficiary other than the

spouse to receive the member’s benefits if the member dies before starting a pension, or

 a former member of a pension plan whose benefits have been transferred to a locked-in

retirement account, life income fund or annuity who has a spouse wishes to designate a

beneficiary other than the spouse to receive the former member’s benefits from the locked-in

retirement account, life income fund or annuity if the former member dies before annuity

payments start.

A spouse who signs Form 4 still has the right to receive survivor’s benefits from the member’s/former

member’s pension or annuity if the member/former member dies after payments start, unless the spouse

waives or gives up those rights by signing Form 2 [Spouse’s Waiver of 60% Lifetime Survivor Benefit

and/or Beneficiary Rights From a Pension Plan or Annuity After Payments Start].

HEN THIS FORM IS NOT REQUIRED

Form 4 is not required if section 145 of the Family Law Act applies to determine the rights of the

member/former member and spouse when the relationship ends. Confirmation that section 145 applies

must be provided to the pension plan administrator, locked-in retirement account issuer, life income

fund issuer or insurance company holding the annuity.

[Please print]

Spouse of member/former member [see definition of “spouse” in section 1 of this form]

Name..............................................................................................................................................................

Address .........................................................................................................................................................

Email address ................................................................................................................................................

Telephone .....................................................................................................................................................

Name of member/former member.................................................................................................................

Address .........................................................................................................................................................

Email address ................................................................................................................................................

Telephone .....................................................................................................................................................

Name of pension plan holding funds/from

which funds were transferred .......................................................................................................................

Address of plan administrator ......................................................................................................................

Plan’s provincial registration number ...........................................................................................................

[Do not complete the following section if the benefits are still in the pension plan]

Name of locked-in retirement account issuer or life income fund issuer

or insurance company holding annuity...........................................................................................................

Address .........................................................................................................................................................

Account number ...........................................................................................................................................

*CSI_OPS_LCK_zzz*

NOV2015

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