Pension Benefits Standards Regulations, 1985
SCHEDULE IV
FORM 1(Subsection 23(2))Statement To Be Provided to a Member Retiring from a Plan
Statement date 
Member’s name Date of birth
Spouse’s or common-law partner’s name Date of birth
Beneficiary
Date employment commenced
Date credited service commenced
Date of attainment of pensionable age
Date of first entitlement to early retirement pension
Credited service
Additional voluntary contributions of member
(a) made during the plan year $
(b) accumulated to date of retirement $
Required contributions of member
(a) made during the plan year $
(b) accumulated to date of retirement $
Employer contributions, in respect of a defined contribution provision, if any,
(a) made during the plan year $
(b) accumulated to date of retirement $
Transfers into the pension plan
(a) lump sum amounts $
(b) benefit attributable to such transfers $
(c) service credited to such transfers
Pension benefit payable to the member
(a) attributable to the benefit formula $
(b) attributable to additional voluntary contributions $
(c) attributable to the "50% rule” $
(d) attributable to any other lump sum amount $
(e) total pension benefit payable $
Pension benefit payable for a limited period
(a) amount $
(b) from
to
Survivor benefit: $
Formula, if any, for indexing the pension benefit
FORM 2(Subsection 23(3))Statement To Be Provided Where the Member Ceases To Be a Member of the Plan or Where All or Part of a Plan Terminates and the Member Is Entitled to a Deferred Pension Benefit
Statement date
Member’s name Date of birth
Spouse’s or common-law partner’s name Date of birth
Beneficiary
Date employment commenced
Date credited service commenced
Date of attainment of pensionable age
Date of first entitlement to early retirement pension
Credited service
Additional voluntary contributions of member
(a) made during the plan year $
(b) accumulated to date of cessation of membership $
Required contributions of member
(a) made during the plan year $
(b) accumulated to date of cessation of membership $
Employer contributions, in respect of a defined contribution provision, if any,
(a) made during the plan year $
(b) accumulated to date of cessation of membership $
Transfers into the pension plan
(a) lump sum amounts $
(b) benefit attributable to such transfers $
(c) service credited to such transfers
Pension benefit payable to the member
(a) attributable to the benefit formula $
(b) attributable to additional voluntary contributions $
(c) attributable to the “50% rule” $
(d) attributable to any other lump sum amount $
(e) total pension benefit payable $
Pension benefit payable for a limited period
(a) amount $
(b) from
to
Survivor benefit prior to early retirement
(a) total benefit $
(b) group insurance offset $
(c) net benefit $
Pension benefit credit for transfer purposes
(a) attributable to the benefit formula $
(b) attributable to additional voluntary contributions $
(c) attributable to the “50% rule” $
(d) attributable to any other lump sum amount $
(e) total pension benefit credit payable $
Solvency ratio, if less than 1
Schedule of transfer payments (if solvency ratio is less than 1)
Formula, if any, for indexing the pension benefit or for calculating the pension benefit credit
FORM 3(Subsection 23(4))Statement To Be Provided to a Member Where the Member Ceases To Be a Member and Is Not Entitled to a Deferred Pension Benefit
Statement date
Member’s name Date of birth
Date employment commenced
Date credited service commenced
Credited service
Lump sum payable to the member
(a) attributable to the member’s contributions accumulated on the interest $
(b) attributable to additional voluntary contributions $
(c) attributable to any other lump sum amount $
(d) total lump sum payable $
FORM 4(Subsection 23(5))Statement To Be Provided when a Member Dies
Statement date
Member’s name Date of birth
Date employment commenced
Date credited service commenced
Credited service
Additional voluntary contributions of member
(a) made during the plan year $
(b) accumulated to date of member’s death $
Required contributions of member
(a) made during the plan year $
(b) accumulated to date of member’s death $
Employer contributions, in respect of a defined contribution provision, if any,
(a) made during the plan year $
(b) accumulated to date of member’s death $
Transfers into the pension plan
(a) lump sum amounts $
(b) benefit attributable to such transfers $
(c) service credited to such transfers
Pension benefit credit payable to the member’s spouse or common-law partner
(a) attributable to the benefit formula $
(b) attributable to additional voluntary contributions $
(c) attributable to the “50% rule” $
(d) attributable to any other lump sum amount $
(e) total pension benefit or pension benefit credit payable $
Solvency ratio, if less than 1
Schedule of transfer payments (if solvency ratio is less than 1)
Formula, if any, for indexing benefit or for calculating the pension benefit credit
- SOR/2001-194, ss. 5, 6
- Date modified: