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 Nova Scotia
1 Contract owner information
Spouse definition
Pension Benefits Act of
Nova Scotia
Spousal status: Spousal status is established as of the day preceding the death of the
contract owner.
Spouse: The spouse of a contract owner, means on the day of reference under
consideration, the person who:
(a) is married to the contract owner, or
(b) is married to the contract owner by a marriage that is voidable and
has not been annulled by a declaration of nullity, or
(c) has gone through a form of marriage with the contract owner, in good
faith, that is void, and they are cohabiting in a conjugal relationship
or, if they have ceased to so cohabit, have cohabited in a conjugal
relationship within the twelve-month period immediately preceding
the entitlement date.
Common-law partner: The common-law partner, means on the day of reference under
consideration, the person who is and has been cohabiting with the
contract owner in a conjugal relationship for a period of at least two years,
neither of them being a spouse.
2 Claimant’s statement
I have read and fully understand the definition of spouse / common-law 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 spouse/common-law 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 spouse/common-law 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-NS-E-08-11
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