Affidavits
OSFI Form 1: Attestation Regarding Withdrawal Based on Financial Hardship
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Name the institution that holds the money, then use Add plan for every federally regulated locked-in plan there that you want to withdraw or transfer from: a locked-in RRSP, life income fund, restricted life income fund or restricted locked-in savings plan. Add at least one plan; an empty list prints a blank line.
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ATTESTATION REGARDING WITHDRAWAL BASED ON FINANCIAL HARDSHIP
OSFI Form 1, Schedule V, Pension Benefits Standards Regulations, 1985
To: ______
Federally regulated locked-in plans held by that institution from which I intend to withdraw or transfer money:
• ______, account number ______
I, ______, of ______, in the city of ______, in the province of ______, MAKE OATH AND SAY:
I am the owner of the federally regulated locked-in plans listed above.
On the day I sign this attestation, I ask to withdraw money from those plans on the basis of ______.
During this calendar year I have made no other withdrawal under paragraph 20(1)(d), 20.1(1)(m), 20.2(1)(e) or 20.3(1)(m) of the Pension Benefits Standards Regulations, 1985, apart from any withdrawal made in the 30 days before this application.
The amounts in the worksheet below are true to the best of my knowledge.
Amount sought for withdrawal (item 4 worksheet)
Line | Description | Amount |
A | My expected income for this calendar year, worked out under the Income Tax Act | $______ |
B | Total financial hardship withdrawals I have already made this calendar year from all my federally regulated locked-in plans | $______ |
B(i) | Part of B withdrawn because of low income | $______ |
B(ii) | Part of B withdrawn because of medical or disability-related costs | $______ |
C | Half of the Year's Maximum Pensionable Earnings as defined in the Pension Benefits Standards Act, 1985 | $______ |
Maximum withdrawal and amount sought
F(i) | D plus E (0 for a component I am not seeking) | $______ |
F(ii) | C minus B | $______ |
F(iii) = F | Maximum eligible withdrawal: the lower of F(i) and F(ii) | $______ |
G | Amount I ask to withdraw: F or less | $______ |
Signed and sworn (or affirmed/declared) before me by videoconference in Ottawa, Ontario, while the Affiant(s)/Declarant(s) were located in ______________________, on ______________________, pursuant to O. Reg. 431/20, and Electronic Commerce Act, 2000.
______________________________ | ______________________________ |