Approved by the Superintendent of Financial Services pursuant to the Pension Benefits Act, R.S.O. 1990, c. P.8
In this form, “PBA” refers to the Pension Benefits Act, R.S.O. 1990, c. P.8., and “Regulation” refers to Regulation 909, R.R.O. 1990
This Application may only be used to apply for money in your locked-in account that was earned in Ontario.
Submit your completed Application to the financial institution that administers your locked-in account.
Do not submit it to the Financial Services Commission of Ontario (FSCO).
NOTE: Please read the User’s Guide to ensure this Application is filled out completely and correctly.
Use this Application to apply to withdraw money from an Ontario locked-in retirement account, life income fund or locked-in retirement income fund (referred to in this Application as a locked-in account) based on financial hardship for low expected income.
You cannot apply to withdraw money from this locked-in account under the category of low expected income more than one time during a calendar year.
You must apply to withdraw at least $500 and cannot apply to withdraw more than the maximum amount permitted by regulation.
If your application is approved, the money will be paid to you in one lump sum. The money cannot be paid out in any other interval, nor transferred to a Registered Retirement Savings Plan (RRSP) or a Registered Retirement Income Fund (RRIF). Also, any amount you withdraw from your account cannot subsequently be re-deposited in any locked-in account.
Please be aware that the amount that is approved will be reduced by the amount of tax that is required to be withheld. There may be additional amounts that may be deducted. You should ask your financial institution for an estimate of the amount that will be deducted before you decide how much money you want to apply to withdraw, but you cannot apply for an amount greater than the maximum amount permitted by Regulation.
Any withdrawal from your locked-in account may affect your eligibility for certain government benefits. To find out more, contact the government department or agency that provides these benefits.
When money is withdrawn from an Ontario locked-in account, the money will lose the creditor protection provided by the PBA and Regulation. In addition, any withdrawal you make from your locked-in account will decrease the amount of retirement income you receive or will receive in the future.
This form, including the required information, signatures, and supporting documents, is required by the Regulation, Schedule 1, Schedule 1.1, Schedule 2, or Schedule 3 to the Regulation, as applicable.
Note: Under privacy legislation, it is the responsibility of your financial institution to advise you of the purposes for which personal information is collected, used or disclosed. Your financial institution and its representatives are required to comply with all applicable privacy requirements in dealing with information required to be provided as part of this Application.
Street Number and Name:
Province / State:
Postal Code / Zip Code:
Enter area code
Enter telephone number
Fax Number: Enter area code
Enter fax number
Name of Financial Institution and Policy Number or Account Number of your Ontario locked-in account:
Spouse's Mailing Address
Same as your Mailing Address, or:
Province / State:
Postal Code / Zip Code:
The maximum amount you can withdraw is:
Note that you are not permitted to apply to withdraw an amount:
Please read the User’s Guide before you complete the Certification.
This Certification will not be valid for the purpose of your Application if it is dated more than 60 days before the date the financial institution that administers your Ontario locked-in account receives this completed Application.
I own the locked-in account identified in Part 1 of this Application. I hereby apply to withdraw from the locked-in account the amount set out in Part 2 of this Application. I understand that the amount that is approved will be reduced by withholding tax payable on the money withdrawn from the account and an additional amount that may be deducted by my financial institution.
I certify that on the date I sign this Part:
(Check only one of the options below.)
I have a spouse*, and my spouse consents to the withdrawal of money from the locked-in account. (If you check this box, you will need your spouse to complete Part 4 of this Application.)
I have a spouse*, but on the date I sign this Certification, I am living separate and apart from my spouse as a result of a breakdown in our spousal relationship.
I have a spouse*, but none of the money in my locked-in account is derived, directly or indirectly from a pension benefit provided in respect of my past or current employment. (See User's Guide for an explanation and examples.)
I do not have a spouse*.
I also certify that:
I understand that:
*Please refer to the User’s guide for the definition of “spouse” under the Ontario Pension Benefits Act.
The owner of the locked-in account must sign this Certification in the presence of an adult witness.
Signature of Owner
Signature of Witness
This Part needs to be completed only if the owner of the locked-in account attests in Part 3 of this Application that the owner has a spouse who consents to the withdrawal of money from the account. The owner of the locked-in account cannot complete this Part.
If you are the spouse of the owner of the locked-in account and you are asked to consent to this Application to withdraw money from the owner’s account, you should get advice from a lawyer about your rights and the legal consequences of signing the Consent below. You are not obligated to sign the Consent below.
If you wish to consent, please read the Consent below. If you are satisfied that the Consent correctly describes your situation, in the presence of a witness (an adult who is not the owner of the locked-in account), please sign, date and fill in the required information, and have your witness sign the Consent.
The Consent will not be valid for the purposes of this Application if the Consent is dated more than 60 days before the date the financial institution receives it.
I am the spouse of the owner of the locked-in account identified in Part 1 of this Application.
I understand that:
I consent to the owner’s Application to withdraw money from the locked-in account.
I give my consent by signing and dating this Consent in the presence of a witness.
Signature of Owner's Spouse
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