Pooled Registered Pension Plans Regulations (SOR/2012-294)

1 To (insert name of financial institution)

2 List of applicable locked-in plans: (Please identify all locked-in registered retirement savings plans, life income funds, restricted locked-in savings plans or restricted life income funds that are held by the financial institution identified above and from which you intend to withdraw or transfer funds.)

(a)

(b)

(c)

3 Certification

I, (insert name) , of (insert street address), in the city of , in the province of , certify the following:

I own the plan(s) identified in section 2. On the day on which I sign this certification (select all that apply)

(A) Withdrawal for expenditures on medical or disability-related treatment or adaptive technology
(a)	My total expected income for the calendar year, determined in accordance with the Income Tax Act (excluding the withdrawal referred to in item G of the table to section 4 and any withdrawal made under paragraph 38(1)(e), 39(1)(f), 40(1)(k) or 41(1)(k) of the Pooled Registered Pension Plans Regulations within the last 30 days before the day on which this certification is made), is $.
(b)	I submit a letter signed by a physician certifying that medical or disability-related treatment or adaptive technology is required.
(c)	I expect to make expenditures on the medical or disability-related treatment or adaptive technology specified in the physician’s certificate in the amount of $, which is greater than 20% of my total expected income for the calendar year.
(d)	I have not made any other withdrawal, other than within the last 30 days before the day on which this certification is made, during the calendar year under paragraph 38(1)(e), 39(1)(f), 40(1)(k) or 41(1)(k) of the Pooled Registered Pension Plans Regulations.
(B) Withdrawal based on low income
	My total expected income for the calendar year, determined in accordance with the Income Tax Act (excluding the withdrawal referred to in item G of the table to section 4 and any withdrawal made under paragraph 38(1)(e), 39(1)(f), 40(1)(k) or 41(1)(k) of the Pooled Registered Pension Plans Regulations within the last 30 days before the day on which this certification is made) is less than 75% of the Year’s Maximum Pensionable Earnings as defined in the Pooled Registered Pension Plans Act.

4 Amount Sought for Withdrawal

Amount Sought for Withdrawal
A	Expected income in this calendar year, determined in accordance with the Income Tax Act	$
B	Total financial hardship withdrawals made during the calendar year from all federally regulated locked-in registered retirement savings plans, life income funds, restricted life income funds and restricted locked-in savings plans.	$
	B(i): total low income component of B is	$
	B(ii): total medical and disability-related income component of B is	$
C	50% of the Year’s Maximum Pensionable Earnings as defined in the Pooled Registered Pension Plans Act.	$
Calculation of Low Income Component Of Withdrawal
(To be completed only if seeking withdrawal under this component.)
D	Low income withdrawal component.
	Enter amount from D(iv) if that amount is greater than zero otherwise enter “0”			$
	D(i)	A – B	$
	D(ii)	66.6% of D(i)	$
	D(iii)	C – D(ii)	$
	D(iv)	D(iii) - B(i)	$
Calculation of Medical and Disability-Related Component of Withdrawal
(To be completed only if seeking withdrawal under this component.)
E	Total expected medical and disability-related expenditures for which withdrawal is being sought.
	Enter amount from E(v)			$
	E(i) Total expected medical and disability-related expenditures in the calendar year that a medical doctor certifies are required.		$
	E(ii)	A – B	$
	E(iii)	20% of E(ii)	$
	E(iv)	If E(i) is greater than or equal to E(iii) enter E(i), otherwise enter “0”	$
	E(v)	Enter the lesser of E(iv) and C	$
Calculation of Financial Hardship Withdrawal
(To be completed only if seeking withdrawal under this component.)
F	Total amount eligible for financial hardship withdrawal.
	Enter amount from F(iii)			$
	F(i)	D + E	$
	F(ii)	C – B	$
	F(iii)	Enter the lesser of F(i) and F(ii)	$
G	Total amount applicant wishes to withdraw.
	Enter F or a lesser amount			$

5 Signatures

Sworn before me, on the day of

, 20 ,

at , in the province of

.

A person authorized to take affidavits

1 To (insert name of financial institution)

2 List of applicable locked-in plans (Please identify all locked-in registered retirement savings plans, life income funds, restricted locked-in savings plans or restricted life income funds that are held by the financial institution identified above and from which you intend to withdraw or transfer funds.)

(a)

(b)

(c)

3 Certification of applicant

I, (insert name) , of (insert street address) , in the city of , in the province of , certify the following:

I own the locked-in plan(s) identified in item 2. I intend to withdraw or transfer the amount of $ from the plan(s). On the day on which I sign this certification (check one)

(a)	I do not have a spouse or common-law partner, as defined in subsection 2(1) of the Pooled Registered Pension Plans Act.
(b)	I have a spouse or common-law partner, as defined in subsection 2(1) of the Pooled Registered Pension Plans Act and my spouse or common-law partner consents to the withdrawal of the amount specified above from the locked-in plan(s) identified in item 2. (If you check this box, your spouse or common-law partner must complete the Certification of Spouse or Common-law Partner in item 6 below.)

4 Acknowledgements

I understand that when funds are withdrawn or transferred from any locked-in plan, the funds may lose the creditor protection provided by the Pooled Registered Pension Plans Act and the Pooled Registered Pension Plans Regulations.

I understand that when funds are withdrawn or transferred from any locked-in plan, the funds may be taxable under the Income Tax Act or other legislation.

I understand that I may need to seek professional advice about the financial and legal implications of such a withdrawal or transfer.

5 Signatures

Sworn before me, on the day of

, 20 ,

at , in the province of

.

A person authorized to take affidavits

6 Certification of Spouse or Common-law Partner

I, (insert name) , of (insert street address) , in the city of , in the province of , certify the following:

I am the spouse or common-law partner of the owner of the locked-in plan(s) identified in item 2.

I understand that

• (a) the applicant intends to withdraw or transfer funds from the locked-in plans identified in item 2, which withdrawal or transfer is not permitted unless the applicant obtains my consent;

• (b) as long as those funds are kept in that locked-in plan, I may have a right to a share of those funds if there is a breakdown in our relationship or if the owner dies;

• (c) if any funds are withdrawn or transferred from that locked-in plan, I may lose any right that I have to a share of the funds withdrawn or transferred;

• (d) when funds are withdrawn or transferred from any locked-in plan the funds may lose the creditor protection provided by the Pooled Registered Pension Plans Act and the Pooled Registered Pension Plans Regulations;

• (e) when funds are withdrawn or transferred from any locked-in plan the funds may be taxable under the Income Tax Act or other legislation; and

• (f) I may need to seek professional advice about the financial and legal implications of such a withdrawal or transfer.

7 Consent of Spouse or Common-law Partner

I consent to the withdrawal or transfer specified in item 3.

8 Signatures

Sworn before me, on the day of

, 20 ,

at , in the province of

.

A person authorized to take affidavits

1 To (insert name of financial institution)

2 List of applicable locked-in plans (Please identify all locked-in registered retirement savings plans, life income funds, restricted locked-in savings plans or restricted life income funds that you own including all those that are held by financial institutions other than the one identified above.)

(a)

(b)

(c)

3 Certification

I, (insert name) , of (insert street address), in the city of , in the province of , certify the following:

I own the locked-in plans identified in item 2. On the day on which I sign this certification the total value of all of the locked-in plan(s) identified in item 2 is $.

The total value of all of the locked-in plan(s) identified in item 2 is less than 50% of the Year’s Maximum Pensionable Earnings as defined in the Pooled Registered Pension Plans Act.

4 Signatures

Sworn before me, on the day of

, 20 ,

at , in the province of

.

Signature of applicant

A person authorized to take affidavits