First name of the deceased contract owner Middle name Last name Contract number
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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
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Spousal status declaration
for deceased contract owner
Locked-in funds in Quebec
1 Contract owner information
Spouse definition
Supplemental Pension Plans
Act (Quebec)
Spousal status: Spousal status is established as of the day preceding the death of the
contract owner
Spouse: The spouse, in relation to the contract owner, means on the day of
reference under consideration, the person who:
1) is married to or in a civil union with the contract owner, or
2) has been living in a conjugal relationship with a contract owner who
is neither married nor in a civil union, whether the person is of the
opposite or the same sex, for a period of not less than three years, or
for a period of not less than one year if:
• at least one child is born, or to be born, of their union;
• they have adopted, jointly, at least one child while living together
in a conjugal relationship; or
• one of them has adopted at least one child who is the child of the
other, while living together in a conjugal relationship.
For the purposes of paragraph (2) above, the birth or adoption of a child
during a marriage or civil union or a period of conjugal relationship prior
to the period of conjugal relationship existing on the day as of which
spousal status is established may qualify a person as a spouse.
Notwithstanding paragraph (1) above, a person who is legally separated
from bed and board on the day as of which spousal status is established is
not entitled to any benefit under this subdivision unless the person is the
contract owner’s successor or if the contract owner had notified the pension
committee in writing to pay the pension to the spouse notwithstanding the
divorce, annulment of marriage, annulment of civil union, separation from
bed and board or cessation of conjugal relationship.
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 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.
at the contract owner’s date of death, I was, and continue to be, the executor/liquidator and, to the best of knowledge, no
person fulfilled the conditions required to be considered the contract owner’s spouse or has been designated as a beneficiary.
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-QC-E-08-11
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