(Please Print)

To:                                          Administrator of pension plan

                Name of Plan:                                                                                                                                                     

                Address of Plan:                                                                                                                                                 

                From:                                     Spouse of member (Note: spouse includes a former spouse.)

                Name:                                                                                                                                                                   

                Address:                                                                                                                                                               

                Home Phone:                                                                             Work Phone:                                                  

                Social Insurance Number:                                                                                                                                               

                In relation to:                        Plan member

                Name of member:                                                                                                                                              

                Address:                                                                                                                                                               

                Home Phone:                                                                             Work Phone:                                                  

                Social Insurance Number:                                                                                                                                               

                Employer:                                                                                                                                                             

Declaration of spouse claiming interest

I,                                                                (name of spouse) declare that

                (a)           I was married to the member named above on                                                           (date),

                (b)           I was separated from the member on                                                            (date), and

(c)                 I am claiming an interest in the member’s pension based on section 43 (1) of the Family Relations Act (see below).

Signed (spouse):                                                                                                                              

                                Date of Declaration:                                                                                                                         

                                Signed:                                                                                                                                               

                                (witness to signature of spouse)

                                Name of Witness:                                                                                                                            

                                Address of Witness:                                                                                                                        

Family Relation Act, section 43:

(1)                 Subject to this Part and Part 3.1, each spouse is entitled to an interest in each family asset on or after March 31, 1979, when

                (a)           a separation agreement,

                                                    (b)           a declaratory judgement under section 44,

                (c)           an order for dissolution of marriage or judicial separation, or

                                                    (d)           an order declaring the marriage null and void

respecting the marriage is first made.