FormP4(DivisionofPensionsRegulation,s.4(d))
REQUEST BY LIMITED MEMBER FOR TRANSFER OR SEPARATE PENSION
WhentoUse this Form
AFormP4isusedbyalimitedmembertochoosehowtoreceiveashareofbenefitsunderadefinedbenefitprovisionifthememberisnotyetreceivingapension.
[Please print]
To: Administrator of plan/annuity issuer
Name of plan/annuity - Telecommunication Workers Pension Plan
Address of administrator/annuity issuer - #303-4603 Kingsway
Burnaby, BC V5H 4M4
From:Spouse of member[Note: "spouse" includes a personwho has livedin a marriage-like relationship withthememberforacontinuousperiodofatleast twoyears andalsoincludesa formerspouse.]
Name of spouse......
Address ......
......
Email address ......
Telephone (home) ...... (work) ......
Social Insurance Number ......
Date of birth ......
[Thisadministrator will use this information tocontact you about important matters.Make sure it is accurate and that youpromptly advise theadministratorofany changes.]
In relation to:
Plan member
Name of member ......
Address......
......
Email address ......
Telephone (home) ...... …….... (work) ...... …......
Social Insurance or Pension Plan Identity Number ...... ………......
Employer of member ......
Request
As the limited member named above, I request [Check the correct box.] that you
(a)transferfromtheplanmyproportionateshareofthecommutedvalueofthe member’sbenefitsinaccordancewiththeFamilyLawActandthe PensionBenefits Standards Act.
(b)that youprovide me with a separatepensionfromtheplan,
To be effective the first of the month following receipt of this form by the Plan office (a retirement package will be sent to you), OR
At a future date, to be applied for no later than the month prior to retirement (an application will be sent to you). You cannot defer the pension past the date your former spouse elects to retire.
[Theseoptionsareonlyavailableafterthememberisallowedtoreceiveapensionbutthepensionhasnotyet commenced.]
Signed (limited member) ......
Date ......
Signed (witness to signatureoflimitedmember)
......
Name of witness
......
Addressofwitness
......
Office use onlyStatement of Trustees
In accordance with the terms and conditions of the Plan you are hereby authorized to transfer an amount of
$______plus interest to the Financial Institution.
______
DateTrusteeTrustee