Form 1 "Application for Registration" - Nova Scotia, Canada

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Form 1
Application for Registration
Finance and Treasury Board
For Staff Use Only
Stamp
Entered:
Cheque No:
Amount:
$
Reviewed:
Use this form to register a pension plan with the Province of Nova Scotia.
Do NOT use this form for a pension plan regulated by another province or the federal
government.
Complete this form and send it with all required documents to the Superintendent of
Pensions within 60 days of establishing the plan.
This form is approved by the Superintendent of Pensions under the Pension Benefits Act.
1
Give plan information
G
Name of plan:
Registration number:
2
Give plan administrator’s contact information
G
If the administrator is a corporation, pension committee, or board, use the name of the corporation,
committee, or board.
Name of the administrator:
Name and title of contact person:
Address:
Postal code:
Email:
Phone number:
Fax number:
3
Describe the plan administrator
G
3A What is the status of the administrator? Choose one of the following:
Employer or group of employers
Pension committee - Answer 3B below.
Insurance company
Board of trustees
Board, agency, or commission who must, by law, administer the plan
Page 1 of 7
novascotia.ca/finance/en/home/pensions/default.aspx
Form 1
2015/01
Form 1
Application for Registration
Finance and Treasury Board
For Staff Use Only
Stamp
Entered:
Cheque No:
Amount:
$
Reviewed:
Use this form to register a pension plan with the Province of Nova Scotia.
Do NOT use this form for a pension plan regulated by another province or the federal
government.
Complete this form and send it with all required documents to the Superintendent of
Pensions within 60 days of establishing the plan.
This form is approved by the Superintendent of Pensions under the Pension Benefits Act.
1
Give plan information
G
Name of plan:
Registration number:
2
Give plan administrator’s contact information
G
If the administrator is a corporation, pension committee, or board, use the name of the corporation,
committee, or board.
Name of the administrator:
Name and title of contact person:
Address:
Postal code:
Email:
Phone number:
Fax number:
3
Describe the plan administrator
G
3A What is the status of the administrator? Choose one of the following:
Employer or group of employers
Pension committee - Answer 3B below.
Insurance company
Board of trustees
Board, agency, or commission who must, by law, administer the plan
Page 1 of 7
novascotia.ca/finance/en/home/pensions/default.aspx
Form 1
2015/01
Form 1 Application for Registration
3B Answer the following questions ONLY if the administrator is a PENSION COMMITTEE.
How many members of the committee represent employers or
anyone required to make contributions on behalf of an employer?
How many members of the committee are also members of the plan?
How many people in total are on the committee?
4
Give contact information of employer or sponsor
G
Name of employer or sponsor:
Address:
Postal code:
Email:
Phone number:
Fax number:
If the employer’s or sponsor’s name or address changes, inform the superintendent in writing
within 60 days of the change.
5
Give additional employer information
G
Do other employers have employees participating in the plan? Include subsidiary or affiliated companies.
Yes - Attach the following information to this form: additional employer’s name, additional employer’s
address , and additional employers’ main business.
No
6
What kind of organization is the plan being registered for?
G
Public sector
Municipal government
Municipal enterprise
Federal government
Federal enterprise
Provincial government
Provincial enterprise
Other
Private sector
Incorporated business
Unincorporated business (sole proprietor or partnership)
Co-operative
Trade or employee association
Religious, charitable, or other non-profit organization
Other
Page 2 of 7
novascotia.ca/finance/en/home/pensions/default.aspx
Form 1
2015/01
Form 1 Application for Registration
7
Give consultant’s contact information
G
Name of the consultant:
Consultant’s position or title:
Name of consulting firm:
Address:
Postal code:
Email:
Phone number:
Fax number:
Attach an extra page listing all other applicable contacts such as third party administrators, plan auditor,
custodian, affiliates, associates, or subsidiary company of the principal employer.
8
Describe the plan
G
Are the employer contributions to the plan required under a collective agreement?
Yes
No
Does the plan have any defined benefit provisions?
Yes
No
When is the effective date of the plan? (yyyy/mm/dd)
When is the plan’s fiscal year end? (mm/dd)
Note: The plan’s fiscal year end is December 31st unless the plan sets a different date.
What kind of plan is being registered? Put a mark in the corresponding circle.
Defined
Defined
Combination of
benefit
contribution
defined benefit and
defined contribution
Single employer
Multi-employer
Other, give details:
Page 3 of 7
novascotia.ca/finance/en/home/pensions/default.aspx
Form 1
2015/01
Form 1 Application for Registration
Is the plan a multi-employer plan created as part of a collective agreement or trust agreement; or a plan
that provides defined benefits where the obligation of an employer to contribute to the plan is limited to a
fixed amount or rate set out in a collective agreement?
Yes
No
Is the plan a “designated plan” as defined in the federal Income Tax Regulations?
Yes
No
9
Where are the funds held?
G
Choose one from the following list:
Benefits fully insured or guaranteed by an insurance company
Contract with an insurance company but the benefits are NOT fully insured or guaranteed
Trust agreement with individual trustees
Trust agreement with trust company
Pension funds society
Government, agency, board, or commission established by law to administer a pension fund
Other, give details
10
Give information regarding the funding arrangement
G
Company name (include the name of the corporate trustee, insurance company, or other body which holds
the fund’s assets):
Policy or trust account number:
Address:
Postal code:
Email:
Phone number:
Fax number:
Page 4 of 7
novascotia.ca/finance/en/home/pensions/default.aspx
Form 1
2015/01
Form 1 Application for Registration
11
Give numbers of employees enrolled in the plan on the effective date of the plan
G
Area of employment
Male
Female
Total
Newfoundland & Labrador
0
Prince Edward Island
0
Nova Scotia
0
New Brunswick
0
Quebec
0
Ontario
0
Manitoba
0
Saskatchewan
0
Alberta
0
British Columbia
0
Yukon Territory
0
Northwest Territories
0
Territory of Nunavut
0
Canada*
0
Totals
0
0
0
*
Plan members working in the following areas come under the authority of the federal pension benefits
standards legislation. Give their area of employment as Canada:
Air, water, and rail transportation
Interprovincial trucking
Radio, television, and telegraph
Atomic energy
Flour, feed, or seed mills
Chartered banks
12
Calculate the fee
G
Total fee owing: Total number of members (excluding members from PEI) x $5.80 =
If your total is LESS THAN $116.65 you must pay $116.65
If your total is MORE THAN $8,749.75, you must pay $8,749.75
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Form 1
2015/01
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