Form 11 Withdrawal from lira or lif
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| Form 11 Withdrawal from LIRA or LIF: • Life expectancy less than 2 years • Non-residency • Small amount at age 65 • Excess amount transferred Page 1 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Finance and Treasury Board Why complete this form? Use this form if you want to withdraw or transfer money from your locked-in retirement account (LIRA) or life income fund (LIF).
Yes. Continue to the next question. No. Do not use this form; contact the jurisdiction where the LIRA or LIF was earned. Was the LIRA or LIF earned while working for a company regulated by the federal government?
Yes. Do not use this form; contact the financial institution that holds your account. No. Continue to the next question. Why do you want to withdraw or transfer money?
I have an illness or disability that is likely to shorten my life expectancy to less than two years. I do not live in Canada and have been out of the country for at least 24 months.
I am 65 or older and have less than $26,800 in all of my LIRAs and LIFs combined. I have transferred an amount of money from my pension plan that exceeds the limit allowed
Have you considered other effects of withdrawing or transferring this money?
Your taxes. Contact the Canada Revenue Agency at 1-800-959-8281 to find out how your taxes may be affected.
Your eligibility for certain government benefits. Contact the government department that provides those benefits to see how they may be affected.
Creditor protection. Money you withdraw is no longer protected from your creditors under the Pension Benefits Act. Page 2 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Form 11 Withdrawal from LIRA or LIF 1 G
Give your personal information Last name: First name: Middle name: Address: Postal code: Phone number: Date of birth (yyyy/mm/dd): 2 G
Give information about the LIRA or LIF LIRA or LIF account number: Name of the financial institution looking after the LIRA or LIF: Address: Postal code: Phone number:
G
Where was the money in the LIRA or LIF transferred from? my pension plan with a former employer a former spouse’s pension plan after the breakdown of our relationship
G
Where was the pension earned by you or your former spouse? Company name:
Province of employment: 5 G
Attach a copy of the most recent statement from your LIRA or LIF Statement attached. 6 G
Attach one of the following declarations and supporting documents a 6A1 Declaration in support of a withdrawal related to illness or disability (see page 4) a 6A2 Physician’s Statement (see page 5) a 6B Declaration in support of a withdrawal by a non-resident of Canada (see page 6) a 6C Declaration in support of a withdrawal after age 65, where the total value of all plans
is less than $26,800 (see page 7) a 6D Declaration in support of a withdrawal related to an amount exceeding Income Tax Act
limits (see page 9) 7 G
Attach an Owner’s Certificate for the LIRA or LIF Owner’s certificate attached, which is signed and witnessed (see page 10) Page 3 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Form 11 Withdrawal from LIRA or LIF 8 G
Attach a Spouse’s Consent to the withdrawal or transfer, if needed Spouse’s consent attached, which is signed and witnessed (see page 11) I have no spouse as defined in the Pension Benefits Act (see our definition of spouse on page 12)
application form for each account. It is an offence under the Criminal Code for anyone to knowingly make or use a false document with the intent that it be acted upon as genuine. This form is approved by the Superintendent of Pensions under the Pension Benefits Act. 9 G
Give this application to the financial institution that looks after your LIRA or LIF. Do not give this application to the Department of Finance and Treasury Board, Pension Regulation Division Questions? Call 902-424-8915 or email pensionreg@novascotia.ca
Page 4 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Finance and Treasury Board Form 11- 6A1 Declaration in support of a withdrawal related to illness or disability I declare that I have an illness or disability that is likely to shorten my life expectancy to less than two years. G
Declare the amount you want to withdraw $
All of the money in my LIRA or LIF G
Attach one of the following from your doctor A Physician’s Statement signed and completed by your doctor. (see page 5 of this form) A letter signed by your doctor stating that they are licensed to practise medicine in Canada
and that it is their opinion that you will likely live for less than two years due to your illness or disability. Page 5 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Finance and Treasury Board Form 11- 6A2 Physician’s Statement Give your opinion for the purposes of the owner’s application. or
Give your opinion in another written format, such as a letter. It must contain the following statements: • that you are a physician licensed to practise medicine in Canada • that, in your opinion, the owner has an illness or disability that is likely to shorten his or her life expectancy to less than two years
G
Last name: First name: Middle name: Address: Postal code: Phone number: G
I am a physician licensed to practise medicine in Canada. In my opinion, my patient (print the name of your patient) has an illness or disability that is likely to shorten his or her life expectancy to less than two years. Time-sensitive material: This application must be received by the financial institution that looks after the LIRA or LIF within 60 days of signing to be valid.
Date (yyyy/mm/dd): Page 6 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Finance and Treasury Board Form 11- 6B Declaration in support of a withdrawal by a non-resident of Canada I declare that • I am a non-resident of Canada under the Income Tax Act. • I do not live in Canada and have been out of the country for 24 months. • I left Canada on (yyyy/mm/dd): Declare the amount you want to withdraw $
All of the money in my LIRA or LIF Attach a copy of a letter from the Canada Revenue Agency stating that you are a non-resident of Canada under the Income Tax Act. Letter attached.
Page 7 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Finance and Treasury Board Form 11- 6C Declaration in support of a withdrawal after age 65, where the total value of all plans is less than $26,800 I declare that • I am 65 or older. • The total value of all of my LIRAs and LIFs is less than $26,800.
in all of my LIRAs and LIFs including the one from which I want to withdraw money.
Financial institution looking after the LIRA or LIF Policy or account # Date of most recent statement (yyyy/mm/dd) Value of all funds held in LIRA or LIF $
$
$
$ Total $
1 G
Do you want to withdraw money or transfer it to an RRSP or RRIF? Withdraw. Go to question 2 Transfer. Go to question 3
G
Declare the amount you want to withdraw $
All of the money in my LIRA or LIF 3 G
Declare the amount you want to transfer $
All of the money in my LIRA or LIF 0
Page 8 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
4 G
Give information about the RRSP or RRIF into which you want to transfer money RRSP or RRIF account number: Name of the financial institution looking after the RRSP or RRIF: Address: Postal code: Phone number:
limit allowed under the Income Tax Act. Form 11- 6C Declaration in support of a withdrawal after age 65,
Page 9 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Finance and Treasury Board Form 11- 6D Declaration in support of a withdrawal related to an amount exceeding Income Tax Act limits 1 G
Declare the amount you want to withdraw $
, which is less than the maximum allowed. The maximum allowed. Note: The maximum allowed equals the amount that was transferred from your former pension plan into your LIRA or LIF that exceeded the Income Tax Act limit plus any income you earned on that excess amount. Contact the financial institution that looks after your LIRA or LIF and have them calculate this amount for you. 2 G
Attach a statement that sets out the excess amount that was transferred from your pension plan into your LIRA or LIF. Statement from the administrator of my former pension plan attached. Statement from the Canada Revenue Agency attached.
Page 10 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Finance and Treasury Board Form 11- 7 Owner’s Certificate I certify that I own the LIRA or LIF named in this application and am applying to withdraw or transfer money from it. I certify that on the date I sign this certificate, the following statement is true: (Check only one) I do NOT have a spouse. I have attached my spouse’s consent to the withdrawal of money from my LIRA or LIF –
Spousal Consent, page 12 of this form. My spouse has given a written Waiver of Spouse’s Entitlement under a LIRA or LIF to my financial institution in relation to this money. I have a spouse, but we do not live together now and do not intend to live together again in the future, and my spouse is not entitled to any part of the money in the LIRA or LIF because of a court order or domestic contract. I have a spouse but all the money in my LIRA or LIF was originally earned by my former spouse under his or her pension plan, and I became the owner of that money as a result of the breakdown of our relationship. I certify that all of the information in this application is true, complete, and correct. I understand that, in addition to the amount that I have applied to withdraw or transfer from my LIRA or LIF, applicable taxes will be withheld. I understand that any money withdrawn from my LIRA or LIF will no longer be protected from my creditors. This certificate must be signed before a witness. Your witness • must be at least 18 years of age • must NOT be your spouse • must see you sign the form • must sign, print their name, and date this form immediately after seeing you sign and date this form Give information about the witness Last name: First name: Middle name: Address: Postal code: Phone number:
LIRA or LIF within 60 days of signing to be valid.
Date (yyyy/mm/dd):
Signature of witness: Date (yyyy/mm/dd): Page 11 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Finance and Treasury Board Form 11- 8 Spouse’s Consent to Withdrawal or Transfer To be completed by the spouse referred to in the Owner’s Certificate portion of this application. Before signing this consent, you should speak to a lawyer about your rights and the legal consequences of signing this consent.
Last name: First name: Middle name: Address: Postal code: Phone number:
Spouse’s consent I am the spouse of the owner of the LIRA or LIF named in this application. I understand that the owner is applying to withdraw or transfer money from the LIRA or LIF named in this application. I understand that the owner must have my consent to withdraw or transfer the money from the LIRA or LIF. I understand that I do not have to give my consent—it is my choice to consent or not to consent. I understand that while this money is kept in the LIRA or LIF, I may have a right to a share of this money if our relationship breaks down or if the owner dies. I understand that when money is withdrawn or transferred from the LIRA or LIF, I may lose any right that I have to a share of the money that is withdrawn or transferred. I consent to the owner’s application to withdraw or transfer money from the LIRA or LIF. I give my consent by signing and dating this consent in the presence of a witness. This certificate must be signed before a witness. Your witness • must be at least 18 years of age • must NOT be your spouse • must see you sign the form • must sign, print their name, and date this form immediately after seeing you sign and date this form Give information about the witness Last name: First name: Middle name: Address: Postal code: Phone number:
LIRA or LIF within 60 days of signing to be valid.
Date (yyyy/mm/dd):
Signature of witness: Date (yyyy/mm/dd): Page 12 of 12
novascotia.ca/finance/en/home/pensions/default.aspx Form 11
• 2015/05
Form 11- 8 Spouse’s Consent to Withdrawal or Transfer
waiver, and consent Spouse • The person you are married to. • The person you are married to, if the marriage hasn’t been legally ended. • The person you thought you were married to, if you are still living together. • The person you thought you were married to, if you have lived together in the last 12 months. • The person who is your registered domestic partner under the Vital Statistics Act. • The person you have been living with in a sexual relationship for at least one year, if neither of you are married to someone else. • The person you have been living with in a sexual relationship for at least three years, even if one or both are you are married to someone else. Domestic contract A domestic contract means • a written agreement that provides for a division between spouses of a pension benefit, deferred pension, or pension. • a marriage contract as defined in the Matrimonial Property Act
money in financial assets Waiver – a written agreement in which a person gives up a right to something to which they would ordinarily be entitled. For example, a written agreement in which a spouse gives up the right to receive pension benefits to which they would ordinarily be entitled. Consent – permission or approval to do something. Yüklə 65,72 Kb. Dostları ilə paylaş:
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