DIRECT DEPOSIT ONLY FOR INCOME PAYMENT
Provide a blank, personalized cheque marked void or a duly completed written confirmation from the financial institution.
Under section 146.3 of the Income Tax Act (Canada) and any applicable provincial tax legislation, I hereby request:
To change my retirement savings contract – the existing contract (If there is an irrevocable beneficiary on the existing contract, he/she must consent to the change by signing Section 6.) to a:
Registered Retirement Income Fund (RRIF) (For Saskatchewan: If the money comes from a LIRA or a LIF, the spouse’s consent must be provided on the prescribed form.)
Life Income Fund (LIF) (Not available in Saskatchewan)
Restricted Life Income Fund (RLIF) (Federal only)
To fully transfer my Life Income Fund (LIF) to a Restricted Life Income Fund (RLIF) (Federal only) (If there is an irrevocable beneficiary on the existing contract, he/she must consent to the
change by signing Section 6.)
1. ANNUITANT
FundSERV contract
Dealer code Intermediary code
Contract no.
Annuitant’s first and last name (in block letters)
Agent’s telephone number ExtensionAgent
Agency code
S.U.
Agent code
CONVERSION REQUEST
INDIVIDUAL SAVINGS AND RETIREMENT
F12A
June 2021
F12A(21-06) PAGE 1 OF 2
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.
First name Last name
Address
No. Street Apt.
Postal code
City Province
SIN Date of birth Gender:
M
F Language:
English
French
Telephone: Home Work Extension
REGISTERED RETIREMENT INCOME FUND (RRIF) LIFE INCOME FUND (LIF)
TYPE OF REQUEST
1
FORLIFE Series (Income Stage), GS Series or Ecoflextra Series only:
FORLIFE Income
1
Life Surrender Amount (LSA)
2-3
Guaranteed Surrender Amount (GSA)
3
(GS Series only)
Other series/product:
Minimum
4-5
Level
5
: $_______________
FORLIFE Series (Income Stage), GS Series or Ecoflextra Series only:
FORLIFE Income
1
Life Surrender Amount
2-3
Other series/product:
Minimum Maximum Level
4
: $___________________________
Temporary income: Amount $__________ Maximum and lifetime
AMOUNT
6
Gross
6
Net
Net of fees only (default for minimum)
Gross
6
Net (default for maximum) (Not available for LIF)
Net of fees only (default for minimum)
FREQUENCY
7
Monthly (1st to the 28th); Day: ___________
Last day of each month
Quarterly Semi-annual Annual
Monthly (1st to the 28th); Day: ___________
Last day of each month
Quarterly Semi-annual Annual
DATE OF FIRST PAYMENT
8
Mandatory
MODIFICATION OF INCOME
TAX DEDUCTIONS
9
The minimum tax withholding
rate must be observed.
Deduct taxes on the excess of the minimum only (Default)
Deduct taxes on the total payment (including the minimum)
Federal : $_____________ or _____________%
Provincial
10
: $_____________ or _____________%
Deduct taxes on the excess of the minimum only (Default)
Deduct taxes on the total payment (including the minimum)
Federal : $_____________ or _____________%
Provincial
10
: $_____________ or _____________%
SPOUSE’S INFORMATION
(Complete if the spouse’s age is used
to calculate the minimum)
11-12
My age (default)
Spouse’s age
11-12
. Provide the information requested below:
First name:
_________________ Last name: ____________________
Date of birth:
My age (default)
Spouse’s age
11-12
. Provide the information requested below:
First name: _____________________ Last name: _________________________
Date of birth:
1
When investments are made into the FORLIFE Series Income Stage funds, the default type
of income payment is FORLIFE Income.
2
The rate used to calculate the payment is determined based on the Annuitant’s age at the
time the first payment is made.
3
If investments are made in Guaranteed Surrender Series (GS Series) or Ecoflextra Series funds,
the default type of income payment must be LSA or GSA, whichever applies.
4
If the contract includes a life investment (LI), this payment is allowed only if the total payments from
the life investment for a calendar year are lower than the minimum prescribed by law.
5
If selected, may impact the guarantee of the FORLIFE Series, the GS Series or the Ecoflextra Series.
6
For FORLIFE Income, the GS Series or the Ecoflextra Series, the default is gross.
7
If the market value of the contract on the date the request is received is less than $5,000,
annual is the only authorized frequency.
8
If the date of the first payment occurs in the year of the conversion, the total withdrawal amount is taxable.
9
OPTIONAL – Complete only if the client wants taxation higher than that applied following
Canada Revenue Agency (CRA) standards and, if applicable, those of Revenu Québec.
10
Available for Quebec residents only.
11
If the calculation is based on the spouse’s age, his/her signature must appear in Section 5 of this form.
12
If Premiums are invested in the FORLIFE Series, a spouse older than the Annuitant may not be selected.
This rule applies for IAGSRP contracts issued after June 1, 2016.
2. REGISTRATION TYPE
