TO BE COMPLETED BY THE ANNUITANT. CURRENT MARITAL STATUS: (This data is necessary in order to complete prescribed government forms.) Single Spousal Information: Married Common law Divorced Separated Widowed Name: SIN: Birth Date: _
TO BE COMPLETED BY THE ANNUITANT. CURRENT MARITAL STATUS: (This data is necessary in order to complete prescribed government forms.) Single Spousal Information: Married Common law Divorced Separated Name: SIN: Birth Date: Are you the individual who was a member of the pension plan from which the funds originated? Yes No
TO BE COMPLETED BY THE ANNUITANT. CURRENT SPOUSAL STATUS: (This data is necessary in order to complete prescribed government forms.) Single Spousal Information: Married Common law Divorced Separated Name: SIN: Birth Date: Are you the individual who was a member of the pension plan from which locked-in funds originated? Yes No The Normal Retirement Age of the Registered Pension Plan from which the transferring benefit originated is age and, if applicable, the Early Retirement Age is age _________________________________________ ______________________________ Signature of Annuitant Date Accepted by Agora Dealer Services Corp. as Agent for Canadian Western Trust Company 00 Xxxx Xxxxxx, Xxxxx 0000 Xxxxxxx, Xxxxxxx X0X 0X0
TO BE COMPLETED BY THE ANNUITANT. CURRENT MARITAL STATUS: (This data is necessary in order to complete prescribed government forms.) Single Married Common law Divorced Separated Spousal Information: Name: SIN: Birth Date: Are you the individual who was a member of the pension plan from which the funds originated? Yes No Accepted by Agora Dealer Services Corp. as Agent for Canadian Western Trust Company 00 Xxxx Xxxxxx, Xxxxx 0000 Xxxxxxx, Xxxxxxx X0X 0X0
