Data Form for Pension Evaluation upon Marriage Breakdown

Member Name                            __________________________________________
Member Gender                          Male        Female
Member Date of Birth                  __________________________________________
Member Life Expectancy              Normal     Sub-Normal (submit explanation)

Spouse Name                            __________________________________________
Spouse Gender                          Male        Female
Spouse Date of Birth                   __________________________________________
Spouse Life Expectancy               Normal     Sub-Normal (submit explanation)

Company Name                          ___________________________________________
Member Status                          Active       Terminated         Disabled         Retired
Work Schedule                           Full-time               Part-time
Date of Termination / Retirement   ___________________________________________
If Retired, Pre-65 Annual Pension   ___________________________________________
If Retired, Post-65 Annual Pension ___________________________________________
If Retired, Form of Pension Chosen ___________________________________________

Date of Marriage                               ___________________________________________
Spouse Entitlement Date (end date)     ___________________________________________
Calculation Date (current date default) ___________________________________________

Name of Pension Plan                   ___________________________________________
Plan Text/Summary included?            Yes       No
Current Pension Statement included?  Yes       No
Member Profile included? (1)        Yes       No
Authorization included? (2)                Yes       No

External (Written) Report?                 Yes      No
Internal (Telephone) Report?              Yes      No
Fees Enclosed?                                Yes      No

At our website, www.westcoast-actuaries.com, click on LEGAL EVIDENCE then Matrimonial then Matrimonial FAQ for further details about our services and fees.

(1) For members of B.C. Provincial Plans (Public Service / Municipal / College / Teachers), the Member Profile is available free from the Pension Corporation.

(2) Sample authorization wording is:

I, (insert member’s name), hereby authorize the plan administration to reveal details of my pension plan participation to Westcoast Actuaries Inc.

________________       _________      _______________
Member’s Signature           Date           Member’s S.I.N.