Signature of claimant
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Date (dd-mm-yyyy)
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First name (please print) Last name (please print) Date of birth (dd-mm-yyyy)
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Resident address (street number and name) Apartment or suite Telephone number
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City Province/state Country Postal code/ZIP
First name of the deceased contract owner Middle name Last name Contract number
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Spousal status declaration
for deceased contract owner
Locked-in funds in Alberta
1 Contract owner information
Spouse definition
Employment Pension Plans
Act of Alberta
Spousal status: Spousal status is established as of the day preceding the death of the
contract owner
Pension Partner: The pension partner of a contract owner is the person who, on the day of
reference under consideration:
(a) is married to the contract owner and who have not been living
separate and apart for three (3) or more consecutive years
immediately preceding the date of death; or
(b) if there is no such person as in (a) above, has lived together with the
contract owner in a conjugal relationship
i) for a continuous period of at least three (3) years immediately
preceding the date of death; or
ii) of some permanence if there is a child of the relationship by birth
or adoption.
2 Claimant’s statement
I have read and fully understand the definition of pension partner as set out above. I confirm that,
Please check one box only:
at the contract owner’s date of death, I fulfilled the conditions required to be considered the contract owner’s spouse for
the purpose of entitlement to the death benefit or the survivor benefits as applicable.
at the contract owner’s date of death, I was the designated beneficiary and to the best of my knowledge, no person fulfilled
the conditions required to be considered the contract owner’s pension partner.
at the contract owner’s date of death, I was, and continue to be, the executor/liquidator and, to the best of my knowledge,
no person fulfilled the conditions required to be considered the contract owner’s pension partner or has been designated
as a beneficiary.
I, the undersigned claimant, certify that the above statements are true, correct and complete to the best of my knowledge.
I recognize that a false declaration could result in legal procedures against me.
Please send fax or original.4417-AB-E-08-11
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