Residential Loan Application For Reverse Mortgages Page 3
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PROTECTED B (when completed)
Canada
Estimate Request for Canada Pension Plan
Please refer to the Privacy
Notice Statement on the
Retirement Pension and Post-Retirement Benefit
reverse side of this page.
IMPORTANT: You can fill out the form on screen by typing the information in the fields, then print and sign the
completed form, or print a blank form and use a pen. If you use a pen, please print as clearly as possible.
1A. Social Insurance Number
1B. Sex
1C. Date of birth (YYYY-MM-DD)
Male
Female
2.
Given name and initial
Family name
Mr.
Mrs.
Ms.
Miss
3. Mailing address (No., Street, Apt., P.O. Box, R.R.)
City, town or village
Province or territory
Country (If other than Canada)
Postal code
4A. Telephone
4B. Other telephone
Telephone
number(s)
(Refer to Section 5 of the information sheet to help you complete this section.)
5. I would like an estimate of my Canada Pension Plan (CPP) retirement pension.
Please specify any three retirement ages between 40 and 70 for which you would like estimates.
If I retire
at age (40 to 70)
in (year month), what will my estimated retirement pension be at age (60 to 70)?
Estimate 1
65
Estimate 2
Estimate 3
6. Did you or your spouse or common-law partner receive or were either of you eligible to receive Family Allowances or
the Child Tax Benefit for any children born after December 31, 1958?
You
No
Yes
If yes, enter the periods during which you or your spouse or
common-law partner received the benefits. Also list the dates of
Your spouse or
No
Yes
birth of all children born after December 31, 1958.
common-law partner
From
To
Child's date of birth
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
Child 1
Child 2
Note: Please use another sheet of paper if you have more than 2 children.
7. Have you at any time received a Canada Pension Plan disability benefit?
From
To
YYYY-MM-DD
YYYY-MM-DD
If yes, for what
No
Yes
periods?
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada.
Disponible en français
SC ISP-1003 (2014-03-03) E
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