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 Saskatchewan
1 Contract owner information
Spousal definition
Pension Benefits Act, 1992 of
Saskatchewan
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) if there is no such person, with whom the contract owner is
cohabiting as spouses at the relevant time and has been so cohabiting
continuously for at least one year prior to 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 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 my 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-SK-E-08-11
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