Fillable FSCO Family Law Form 3 IMPORTANT (Collège Boréal)

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FSCO Family Law Form 3 IMPORTANT (Collège Boréal)

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For Plan
Administrator
Use
Effective (2013-01-01)
FSCO (1267E.2)
FSCO Family Law Form 3
Page 1 of 2
Financial Services
Commission
of Ontario
Contact Person Authorization
FSCO Family Law Form 3
Approved by the Superintendent of Financial Services pursuant to
the Pension Benefits Act, R.S.O. 1990, c. P.8
IMPORTANT
• Read the User Guide and Questions and Answers before completing this form.
• You may want to get legal advice before completing this form.
• This form should be completed if:
(i) the Plan Member has a Contact Person who is identified under Part C of the Application for Family Law Value
(FSCO Family Law Form 1); or
(ii) the spouse/former spouse of the Plan Member has a Contact Person who is identified under Part D of the
Application for Family Law Value (FSCO Family Law Form 1).
• By completing this form, you are authorizing a contact person to communicate with the pension plan administrator
(Plan Administrator) about the calculation and division of your Family Law Value. [Note: “Family Law Value” means
the “imputed value” under the Ontario Pension Benefits Act.]
• If you have a person who is acting on your behalf under a power of attorney for property or a court order, do not
complete this form. Instead, provide the Plan Administrator with a certified copy of the power of attorney for property
or the court order.
• Send this form to the Plan Administrator with your Application for Family Law Value (FSCO Family Law Form 1). DO
NOT SEND THIS FORM TO THE FINANCIAL SERVICES COMMISSION OF ONTARIO (FSCO).
Part A
Pension Plan Information
Name of Pension Plan
Name of Employer/Union/Professional Association
Plan Administrator
Mailing Address of Plan Administrator (Street Number and Name)
Suite/Floor No.
City
Province
Postal Code
© Queen's Printer for Ontario, 2013
PRINT
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For Plan
Administrator
Use
Effective (2013-01-01)
FSCO (1267E.2)
FSCO Family Law Form 3
Page 2 of 2
Part B
Identify Yourself
I am the:
Plan Member (Active, Former or Retired) Spouse/Former Spouse of the Plan Member
Last Name
First Name and Initials
Date of Birth (yyyy/mm/dd)
Plan Member’s Employee/Pension Plan Identification Number (if known)
Part C
Identify Your Contact Person
Last Name
First Name and Initials
Lawyer
Other
Name of Company/Firm (if applicable)
Mailing Address (Street Number and Name)
Suite/Floor No.
City
Province
Postal Code
Telephone Number (Main)
( )
Telephone Number (Other)
( )
Fax Number
( )
Contact Person E-Mail Address (if known)
Part D
Your Authorization for the Contact Person
I authorize the person identified in Part C above to receive from, provide to, discuss with (by telephone or any other methods of
communication) and request from the Plan Administrator (or the Plan Administrator’s authorized agent or representative) any and all
information that relates to the calculation and division of the Family Law Value.
Signature of the person who is identified in Part B
above
Name of the person who is identified in Part B above
(printed)
Dated (yyyy/mm/dd)
Signature of Witness
Name of Witness (printed)
Dated (yyyy/mm/dd)
Witness Contact Information
Mailing Address (Street Number and Name)
Apt./Unit No.
City
Province
Postal Code
Telephone Number (Main)
( )
© Queen's Printer for Ontario, 2013
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FSCO Family Law Form 3 IMPORTANT (Collge Boral)

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Completed 10 December 2021

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