A. CLIENT INFORMATION
Last name First name Initial Social insurance number /
Business identification number /
Tax identification number
Address City Province Postal code
B. RECEIVING INSTITUTION
IA Clarington Investments Inc.
(As agents for Industrial Alliance Trust Inc.)
30 Adelaide Street East, Suite 1,
Toronto, ON M5C 3G9
iA Clarington account number (if existing account)
1-800-530-0204 1-866-506-9884
Telephone number Fax number
Dealer name Dealer code Financial advisor’s full name Rep code
Telephone number Fax number Dealer account number
Account type:
RSP
Spousal RSP
RIF
Spousal RIF
TFSA
Non-registered
LIRA
LRSP
RLSP
LIF
LRIF
RLIF
PRIF
Fund code Investment instructions $ % Sales charge front-end (0-5%)*
Special instructions:
Invest as per the iA Clarington application form
*Default rate is 0%
Locked-in confirmation – To be completed by iA Clarington
IA Clarington Investments Inc., as agents for the trustee, Industrial Alliance Trust Inc., agrees to administer all locked-in funds transferred under this transfer authorization in accordance
with the governing pension legislation indicated in Section E below. Any subsequent transfer of these locked-in funds to another Trustee or financial institution will be made only to
another registered plan, which must continue to be administered in accordance with legislation of the jurisdiction noted in Section E. No transfer of locked-in funds will be permitted
unless the receiving plan is appropriately registered and in compliance with the applicable pension legislation, regulations and the Income Tax Act (Canada).
X
Authorized signature Date
C. RELINQUISHING INSTITUTION
Please complete one form for each institution.
Relinquishing institution name Account number Telephone number
Address Fax number
Transfer out instructions: All in cash
 All in kind
 Partial in cash
 Partial in kind
Fund code Investment name $ %
D. CLIENT AUTHORIZATION
I hereby authorize the redemption of my investments as described above. I agree to pay any applicable fees, charges or adjustments as disclosed in the prospectus.
X X
Signature of primary account owner/policyholder Date Signature of joint owner/joint policyholder (if applicable) Date
X
Signature of irrevocable beneficiary (if applicable) Date
E. FOR USE BY RELINQUISHING INSTITUTION ONLY
Account type:
RSP
RIF
TFSA
Non-registered
Spousal plan:
Qualifying RIF:
LIRA
LRSP
RLSP
LIF
Yes
Yes
LRIF
RLIF
PRIF
RPP
No
No
Contributor’s last name
Contributor’s first name
S.I.N.
$ $
Amount transferred Indicate locked-in amount transferred
Governing legislation
Contact name Telephone number
Fax number
X
Authorized signature Date
Authorization for Transfers into iA Clarington for
Registered and Non-Registered Investments
Please submit the signed original form to the relinquishing institution and a copy to IA Clarington. For new accounts, please submit a copy of this form with the application.
(18-1040) 08/18-010047-11
This form can be used for transferring registered and non-registered plans, except for the following:
(1) RIF into RSP; (2) RIF/RSP into non-registered; (3) Marriage breakdown or death transfers; (4) RESP Transfers.
Please note: The data entered on this form may be scanned and stored electronically. Please print neatly to ensure completeness, accuracy and machine readability.
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