"Sample Application Form for a One-Time Transfer" - Manitoba, Canada

This fillable "Sample Application Form for a One-Time Transfer" is a document issued by the Manitoba Department of Finance specifically for Manitoba residents.

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SAMPLE APPLICATION FOR A ONE-TIME TRANSFER
Section 21.4 of The Pension Benefits Act of Manitoba and Sections 10.52 – 10.58 of the Regulation
NOTE: Administrators may use this sample to develop their own application form. It is a sample and is not a
prescribed form or form approved by the superintendent under the regulations. Administrators must ensure their form
complies with the requirements in subsection 10.56(4) of the regulation and that their form includes any additional
information they require to facilitate the transfer.
AN APPLICATION MAY ONLY BE MADE IN RESPECT OF A LIF OR LRIF THAT IS LOCKED-IN
UNDER THE PENSION BENEFITS ACT OF MANITOBA AND REGULATION
If you wish to make a One-time Transfer from LIFs, LRIFs or Pension Plans managed by different administrators, you
must make a separate application to each administrator
I - APPLICANT INFORMATION
___________________________________
______________________________________________________
First Name
Last Name
_________________________________________________________________________________________________
Address
________________________________
________________________
__________________
City
Province
Postal Code
_______/_______/_______
________________________
Date of Birth (Day/Month/Year)
Social Insurance Number
II - ADMINISTRATOR INFORMATION
_________________________________________________________________________________________________
Name of Administrator (Financial Institution or Pension Plan)
_________________________________________________________________________________________________
Address
_________________________________
_____________________
__________________
City
Province
Postal Code
Authorized Administrator:
YES
NO
If you are making a One-time Transfer from LIF(s), LRIF(s) or Pension Plan(s) managed by different administrators, you
must authorize one of those administrators to act as the Authorized Administrator and only the Authorized
Administrator will submit a Request to Superintendent of Pension for Written Notice.
III – ONE-TIME TRANSFER INFORMATION
Identify for each of your LIFs, LRIFs or Pension Plans:
Name of the Administrator
Address
Maximum amount that may be transferred from the plan
Amount to be transferred from each plan
Date the information was provided by the administrator
Application for a Prescribed Transfer from a LIF, LRIF or Pension Plan to a PRRIF
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SAMPLE APPLICATION FOR A ONE-TIME TRANSFER
Section 21.4 of The Pension Benefits Act of Manitoba and Sections 10.52 – 10.58 of the Regulation
NOTE: Administrators may use this sample to develop their own application form. It is a sample and is not a
prescribed form or form approved by the superintendent under the regulations. Administrators must ensure their form
complies with the requirements in subsection 10.56(4) of the regulation and that their form includes any additional
information they require to facilitate the transfer.
AN APPLICATION MAY ONLY BE MADE IN RESPECT OF A LIF OR LRIF THAT IS LOCKED-IN
UNDER THE PENSION BENEFITS ACT OF MANITOBA AND REGULATION
If you wish to make a One-time Transfer from LIFs, LRIFs or Pension Plans managed by different administrators, you
must make a separate application to each administrator
I - APPLICANT INFORMATION
___________________________________
______________________________________________________
First Name
Last Name
_________________________________________________________________________________________________
Address
________________________________
________________________
__________________
City
Province
Postal Code
_______/_______/_______
________________________
Date of Birth (Day/Month/Year)
Social Insurance Number
II - ADMINISTRATOR INFORMATION
_________________________________________________________________________________________________
Name of Administrator (Financial Institution or Pension Plan)
_________________________________________________________________________________________________
Address
_________________________________
_____________________
__________________
City
Province
Postal Code
Authorized Administrator:
YES
NO
If you are making a One-time Transfer from LIF(s), LRIF(s) or Pension Plan(s) managed by different administrators, you
must authorize one of those administrators to act as the Authorized Administrator and only the Authorized
Administrator will submit a Request to Superintendent of Pension for Written Notice.
III – ONE-TIME TRANSFER INFORMATION
Identify for each of your LIFs, LRIFs or Pension Plans:
Name of the Administrator
Address
Maximum amount that may be transferred from the plan
Amount to be transferred from each plan
Date the information was provided by the administrator
Application for a Prescribed Transfer from a LIF, LRIF or Pension Plan to a PRRIF
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Name of Administrator
Address
Maximum
Amount to be
Date
(Financial Institution or
Amount
Transferred
information
Pension Plan)
Available *
provided by
Administrator
* The maximum amount available is the maximum amount that may be transferred from the plan (must not exceed 50% of the
amount in the plan), or in the case of a transfer from two or more plans, from each plan
YOU ARE LIMITED TO A ONE-TIME TRANSFER OF UP TO 50% OF THE BALANCE IN ONE OR MORE LIFs, LRIFs, OR
PENSION PLANS TO A PRESCRIBED REGISTERED RETIREMENT INCOME FUND.
IV - PRESCRIBED RRIF ADMINISTRATOR INFORMATION
_________________________________________________________________________________________________
Name of Prescribed RRIF Administrator that will manage and issue the prescribed RRIF contract
_________________________________________________________________________________________________
Address
_________________________________
_____________________
__________________
City
Province
Postal Code
V – TRANSFER CONSENT OF COHABITATING SPOUSE OR COMMON-LAW PARTNER
Subsection 21.4(5) of The Pension Benefits Act requires that if you were a pension plan member and you have a spouse or
common-law partner; and at the time of making the application you are not living separate and apart from the spouse or partner
by reason of a breakdown of your relationship, the One-time Transfer cannot be made unless the spouse or partner consents in
writing by completing ‘Form 4 – Consent to One-time Transfer of Manitoba Locked-In Money’ available on the Office of the
Superintendent’s (OSPC) website.
I do not have a spouse or common-law partner whose consent is required by subsection 21.4(5) of the Act
I do have a spouse or common-law partner whose consent is required by subsection 21.4(5) of the Act. I have
attached a completed Form 4 – Consent to One-time Transfer of Manitoba Locked-In Money
VI – REQUEST TO SUPERINTENDENT OF PENSIONS FOR WRITTEN NOTICE
Only the authorized administrator as designated by the applicant can submit a request to the superintendent.
After receiving the completed application, the Authorized Administrator must request the Superintendent of Pensions to verify
that the superintendent has no record of a previous One-time Transfer by the applicant. The request must include information
as outlined in subsection 10.56(8) of the regulation. If the applicant is requesting a transfer be made from plans administered by
different administrators, each administrator who is not authorized must promptly provide to the administrator the required
information.
The authorized administrator can submit a request one of two ways:
In writing, by completing a 'Request to Superintendent of Pensions for Written Notice’, and mailing or faxing only this form
to the OSPC, or
online, by completing a 'Request to Superintendent of Pensions for Written Notice' form
Application for a Prescribed Transfer from a LIF, LRIF or Pension Plan to a PRRIF
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VII - APPLICANT’S STATEMENT (as per 10.56(4)(d) of the regulation)
I declare that on the date I sign this application:
I have not previously made a One-time Transfer from one or more LIFs, LRIFs or Pension Plans to a prescribed
Registered Retirement Income Fund under section 21.4 of The Pension Benefits Act;
I authorize the administrator that I’ve designated in Section II above, to request to the Superintendent of Pensions to verify
that the Superintendent has no record of a previous One-time Transfer and to provide the superintendent’s response to
each of the administrators, if there is more than one.
All the information contained in this application and the documents that accompany this application are accurate and
complete
Further, I understand no additional One-time Transfer will be permitted under section 21.4 of The Pension Benefits Act of
Manitoba and the Pension Benefits Regulation.
I sign this application form at:
____________________________
________________________
______________________
(city/town)
(province/territory/state)
(country)
this ____________________day of _____________________, 20______
__________________________________________________
(Signature of Applicant)
The application will be void and the transfer will not be made unless the administrator has received the following
information:
A written transfer consent of a spouse or common-law partner, if applicable
A written notice received by the administrator from the Superintendent of Pensions confirming that he or she
is satisfied that a One-time Transfer has not previously been made by the Applicant, and
Any other information the financial institution requires to facilitate the One-time Transfer
The administrator must be satisfied that:
The Applicant is at least 55 yrs old
The administrator has not facilitated and is not aware of a previous One-time Transfer by the
applicant
No part of the amount to be transferred is the subject of an order
i.
Under The Garnishment Act to enforce a maintenance order, or
ii.
Under section 59.3 of The Family Maintenance Act to preserve assets
The Applicant must provide the completed application to the administrator, together with the completed transfer
consent, if required, within 30 days after receiving the application form and the information to be provided under
subsection 10.56(3).
The Administrator(s) must make the One-time Transfer within 90 days after providing the information to be provided to
the applicant under subsection 10.56(3).
Application for a Prescribed Transfer from a LIF, LRIF or Pension Plan to a PRRIF
3 of 3
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