Signature of claimant
X
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 British Columbia
1 Contract owner information
Spouse definition
Pension Benefits Standards
Act of British Columbia
Spousal status: Spousal status is established as of the day preceding the death of the
contract owner
Spouse: The spouse of a contract owner is the person who, on the day of reference
under consideration:
(a) was married to the contract owner and who, if living separate and
apart from the contract owner at the relevant time, had not lived
separate and apart from the contract owner for the two-year period
immediately preceding the relevant time, or, if there is no such person
described in this definition
(b) the person who, at the relevant time, was living and cohabiting with
the contract owner as husband and wife for the two-year period
immediately preceding the relevant time, or
(c) a person of the same gender who, at the relevant time, lived in a
marriage-like relationship with the contract owner for the two-year
period immediately preceding the relevant time.
2 Claimant’s statement
I have read and fully understand the definition of spouse 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 am 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 am 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 partner.
I, the undersigned claimant, certify that the above statement is 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-BC-E-08-11
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