Form 1 and Instructions – Attestation regarding withdrawal based on financial hardship

Document Properties

  • Type of Publication: Form
  • Form 1 follows these instructions

NOTE: If you intend to make more than one withdrawal for financial hardship in the same calendar year, you must do so within 30 days of your first withdrawal. Please note that the 30-day limit cannot be extended.

The financial hardship unlocking provisions of the Pension Benefit Standards Regulations, 1985 (PBSR) allow for funds to be withdrawn based on one of the following or a combination of both:

Low income

The amount that can be unlocked is determined using a sliding scale based on your expected income. If your expected income for the current calendar year (from Jan.1 to Dec. 31) is $0, a withdrawal of up to 50% of the Year’s Maximum Pensionable Earnings (YMPE) or $27,650Footnote 1 in 2017 is permitted. If your expected income is 75% of the YMPE (i.e. $41,475 in 2017) or higher, you have reached the maximum limit for unlocking and are therefore ineligible.   The YMPE in 2017 is $55,300.

High medical or disability-related costs

For financial hardship unlocking based on medical or disability-related costs, these expected costs must be of 20% or more of your expected income for the current calendar year.  You may withdraw an amount up to the full medical or disability-related costs subject to a maximum amount of 50% of the YMPE or $27,650 in 2017 .  The YMPE in 2017 is $55,300.  

This form must be filled out if you wish to make a financial hardship withdrawal. You must also fill out Form 2: Attestation Regarding Spouse/Common-Law Partner. Completed forms must be sent to the financial institution that holds your account. They should be able to answer any questions you may have regarding the forms. Do not send completed forms to the Office of the Superintendent of Financial Institutions (OSFI).

Section 1:

Enter the name of the financial institution that is holding your funds.

Section 2:

List all federally regulated locked-in retirement savings plans (i.e. locked-in registered retirement savings plans, life income funds, restricted locked-in savings plans or restricted life income funds in which you have funds that were transferred from a federally regulated private pension planFootnote 2) from which you wish to unlock funds. Include the account number, the type of plan and the financial institution’s name.

Section 3: Attestation

This section sets out the attestations you must make.

Withdrawing funds based on medical or disability-related costs - 3(A):

Before you can withdraw your funds based on medical or disability-related costs, you must certify the following:

  • The amount of your total expected income for the calendar year excluding the amount you wish to withdraw at this time (amount in line G below) and also excluding any withdrawals you made from a federally regulated locked-in registered retirement savings plan, life income fund, restricted locked-in savings plan or restricted life income fund within the last 30 days before this application) – 3(A)(a).
  • That you have included a letter from your physician certifying that such medical or disability-related treatment or adaptive technology is required – 3(A)(b).
  • That you expect the expenditures to be greater than 20% of your total expected income for the calendar year – 3(A)(c).
  • That you have not already made a withdrawal from a federally regulated locked-in registered retirement savings plan, life income fund, restricted locked-in savings plan or restricted life income fund, other than one that was made within the last 30 days before this application – 3(A)(d).

When completing section 3 of this form, certify each statement by placing a checkmark on the line beside statements 3(A) (a) through (d).

Withdrawing funds based on low-income (3B):

Before you can withdraw your funds based on low-income, you must certify the following:

  • That the amount of your total expected income for the calendar year is less than 75% of the YMPE as defined in the PBSA – 3(B)
  • That you have not already made a withdrawal from a federally regulated locked-in registered retirement savings plan, life income fund, restricted locked-in savings plan or restricted life income fund, other than one that was made within the last 30 days before this application. As there is no separate line for this under 3B, please check the statement under 3(A)(d) to complete the required certification for withdrawals based on low income.

Section 4:

To calculate the amount eligible for unlocking, on the basis of low income or medical or disability-related costs, or both, please fill in Table 4 (Amount Sought for Withdrawal). The following instructions (p.3) will help you fill out Table 4.

Section A

A Expected income in this calendar year determined in accordance with the Income Tax Act. $ Line to fill out__________    

Enter the amount of your expected personal net income for the current year (from Jan. 1 to Dec. 31). You may base this on last year’s net income found on your tax return (T1 Line 236). This is pre-tax net income. It does not mean household income.

Note: If your expected net income for the current year is lower than last year’s net income, use the lower amount.
Note: If you have already made a withdrawal for financial hardship this calendar year, this amount must be included in your expected income in section A. It must also be entered in section B (see below).

Section B

B Total financial hardship withdrawals made during the calendar year from all federally regulated locked-in registered retirement savings plans, life income funds, restricted life income funds and restricted locked-in savings plans. $ Line to fill out__________    
B(i): total low income component of B is $ Line to fill out__________    
B(ii): total medical and disability-related income component of B is $ Line to fill out__________    

B Enter the total amount in dollars you have already withdrawn for the current calendar year (from Jan. 1 to Dec. 31) on the basis of financial hardship. This amount is the total of B(i) and B(ii).

B(i) Enter the total amount in dollars of the amount in B that was withdrawn based on low income.

B(ii) Enter the total amount in dollars of the amount in B that was withdrawn based on medical or disability-related costs.

If you have not withdrawn any money this year, enter “$0” in B, B(i) and B(ii).

Note: If you intend to make more than one withdrawal for financial hardship in the same calendar year, you must do so within 30 days of your first withdrawal.

Section C

C 50% of the Year’s Maximum Pensionable Earnings as defined in the Pension Benefits Standards Act, 1985.     $ Line to fill out__________

Enter the amount that is 50% of the YMPE for the current calendar year. For 2017, this amount is $27,650 (the YMPE in 2017 is $55,300).

Section D: Complete only if seeking Withdrawal based on low-income

D Low income withdrawal component.      
D(i) A-B $ Line to fill out__________  
D(ii) 66.6% of D(i) $ Line to fill out__________  
D(iii) C-D(ii) $ Line to fill out__________  
D(iv) D(iii) – B(i) $  
Enter amount from D(iv) if greater than zero otherwise enter “0”     $ Line to fill out__________

If your expected income is over 75 % of the YMPE (i.e. $41,475 in 2017 ), enter “0” in D and go directly to section E.  Otherwise, to calculate D, do the following:

D(i)
The amount you entered in A Line to fill out _______ minus the amount you entered in B Line to fill out _______ = D(i)

D(ii)
66.6% of the amount in D(i) : D(i) x 0.666 = D(ii) Line to fill out_________

D(iii)
The amount you entered in C Line to fill out _____ minus the amount you entered in D(ii) Line to fill out______ = D(iii)

D(iv)
The amount you entered in D(iii) Line to fill out________ minus the amount entered in B(i) = Line to fill out________
Enter this amount at D.

Section E: Complete only if seeking Withdrawal based on medical or disability-related costs


E
E(i) Total expected medical and disability-related expenditures in the calendar year, that a medical doctor certifies are required.   $ Line to fill out__________  
E(ii) A – B $ Line to fill out__________  
E(iii) 20% of E(ii) $ Line to fill out__________  
E(iv) If E(i) is greater than or equal to E(iii) enter E(i) otherwise enter “0” $ Line to fill out__________  
E(v) Total expected medical and disability-related expenditures for which unlocking is being sought. Enter the lesser of E(iv) and C $ Line to fill out__________  
Enter amount from E(v)     $ Line to fill out__________

The value for E is your permitted medical or disability-related withdrawal component and is equal to the number in E(v). If you are not making a withdrawal based on medical or disability-related expenditures, enter “$0” in E and go directly to section F. Otherwise, to calculate E, do the following:

E(i)
Enter total expected amount of medical or disability-related expenditures. If you do not wish to withdraw on the basis of medical or disability-related expenditure enter “0”.

E(ii)
The amount you entered in A Line to fill out_______ minus the amount you entered in B Line to fill out_____ = E(ii)
(Note: This is the same amount as D(i).)

E(iii)
20% of the amount you entered in E(ii) : E(ii) x 0.20 = E(iii) Line to fill out _____

E(iv)
If the amount you entered in E(i) Line to fill out ________is greater than or equal to the amount you entered in E(iii) Line to fill out________, the amount to enter for line E(iv) is the same as the amount found at E(i).

If the amount you entered in E(i) Line to fill out________ is smaller than the amount you entered in E(iii) Line to fill out________, the amount to enter for line E(iv) is “0”.

E(v)
Compare the amounts you entered in E(iv) Line to fill out_______ and C Line to fill out________. Enter the smaller amount in E(v) and E.

Section F

F Total amount eligible for financial hardship withdrawal.
    $ Line to fill out__________
F(i) D + E $ Line to fill out__________  
F(ii) C – B $ Line to fill out__________  
F(iii) Enter lesser of F(i) and F(ii) $ Line to fill out__________  
Enter amount from F(iii)     $________

The value for F is your total permitted withdrawal for financial hardship. Enter the amount from the following calculations:

F(i)
The amount you entered in D Line to fill out________ plus the amount you entered in E Line to fill out_______ = F(i)

F(ii)
The amount you entered in C Line to fill out_______ minus the amount you entered in B Line to fill out_______ = F(ii)

F(iii)
Compare the amounts you entered in F(i) Line to fill out _________ and F(ii) Line to fill out_________. Enter the smaller amount in F(iii) and F. This is the total maximum amount that is eligible for financial hardship withdrawal.

Section G

G

Total amount sought for withdrawal.

Enter F or a lesser amount

   


$__________

Enter the amount you wish to withdraw. This amount can be less than or equal to the amount found in F.

Section 5:

You must sign this form as a sworn affidavit. This means that you must swear or affirm before a notary public, commissioner or other person authorized to take affidavits that, to the best of your knowledge, the contents of this form are true and accurate.

 


FORM 1
ATTESTATION REGARDING WITHDRAWAL BASED ON FINANCIAL HARDSHIP

1 To: (insert name of financial institution) Line to fill out ____________________________________________

2 List of applicable federally regulated locked-in plans: (Please identify any locked-in registered retirement savings plan, life income fund, restricted locked-in savings plan or restricted life income fund that is held by the financial institution identified above and from which you intend to withdraw or transfer funds.)

  • (a) Line to fill out _________________________________________
  • (b) Line to fill out _________________________________________
  • (c) Line to fill out___________________________________________

3 Attestation

I, (insert name) Line to fill out_________________________, of (insert address) Line to fill out_________________________, in the city of Line to fill out_________________________, in the province of Line to fill out __________________________, attest to the following:

I own the federally regulated locked-in plan(s) identified in item 2. On the day on which I sign this Attestation (choose all that apply):

(A) Withdrawal for Expenditures on Medical or Disability-related Treatment or Adaptive Technology

  1. My total expected income for the calendar year, determined in accordance with the Income Tax Act (excluding the withdrawal referred to in line G below and any withdrawal made 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 within the last 30 days before this application) is $ Line to fill out__________________;
  2. I submit a letter signed by a physician certifying that medical or disability-related treatment or adaptive technology is required;
  3. I expect to make expenditures on the medical or disability-related treatment or adaptive technology specified in the physician’s certificate in the amount of $ Line to fill out________________, which is greater than 20% of my total expected income for the calendar year;
  4. I have not made any other withdrawal, other than within the last 30 days before this application, during the calendar year 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; and

(B) Withdrawal Based on Low Income

  • My total expected income for the calendar year, determined in accordance with the Income Tax Act (excluding the withdrawal referred to in line G below and any withdrawal made 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 within the last 30 days before this application), is less than three quarters of the Year’s Maximum Pensionable Earnings as defined in the Pension Benefits Standards Act, 1985.

4 Amount Sought for Withdrawal

A Expected income in this calendar year determined in accordance with the Income Tax Act. $ Line to fill out ________    
B Total financial hardship withdrawals made during the calendar year from all federally regulated locked-in registered retirement savings plans, life income funds, restricted life income funds and restricted locked-in savings plans. $ Line to fill out ________    
B(i): total low income component of B is $ Line to fill out ________    
B(ii): total medical and disability-related income component of B is $ Line to fill out ________    
C 50% of the Year’s Maximum Pensionable Earnings as defined in the Pension Benefits Standards Act, 1985. $ Line to fill out ________    
Calculation Of Low Income Component Of Withdrawal
(To be completed only if seeking withdrawal under this component)
D Low income withdrawal component.      
D(i) A - B $ Line to fill out________  
D(ii) 66.6% of D(i) $ Line to fill out________  
D(iii) C - D(ii) $ Line to fill out________  
D(iv) D(iii) - B(i) $ Line to fill out________  
Enter amount from D(iv) if greater than zero otherwise enter “0”     $ Line to fill out________
Calculation Of Medical And Disability-Related Component Of Withdrawal
(To be completed only if seeking withdrawal under this component)
 E E(i) Total expected medical and disability-related expenditures in the calendar year that a medical doctor certifies are required.
  $ Line to fill out________  
  E(ii) A - B $ Line to fill out________  
  E(iii) 20% of E(ii) $ Line to fill out________  
  E(iv) If E(i) is
greater than or equal to E(iii) enter E(i)
otherwise enter
“0”
$ Line to fill out________  
  E(v) Total expected medical and disability-related expenditures for which unlocking is being sought. Enter the lesser
of E(iv) and C
$ Line to fill out________  
  Enter amount from E(v)     $ Line to fill out________
Calculation Of Financial Hardship Withdrawal
F Total amount eligible for financial hardship withdrawal.
     
  F(i) D + E $ Line to fill out________  
  F(ii) C – B $ Line to fill out________  
  F(iii) Enter lesser of F(i) and F(ii) $ Line to fill out________  
  Enter amount from F(iii)     $ Line to fill out________
 G Total amount sought for withdrawal.      
  Enter F or a lesser amount     $ Line to fill out________

5 Signatures

Sworn before me, on the Line to fill out______________day of Line to fill out_____________________, 20 Line to fill out________ at Line to fill out________________________, in the province of Line to fill out__________________________.

Signature of applicant Line to fill out________________________

Line to fill out_______________________________
A notary public, commissioner or other person authorized to take affidavits.

Footnotes

Footnote 1

The figures found in the document reflect the amounts for 2017. They are valid for withdrawals up to December 31, 2017. These amounts are based on the Year’s Maximum Pensionable Earnings (YMPE), which is the maximum amount of earnings on which contributions to the Canada Pension Plan (CPP) are based. It is updated annually by the federal government based on the average industrial wage in Canada. You can get information on the CPP pensionable earnings ceiling from the Canada Revenue Agency.

Return to footnote 1

Footnote 2

A federally regulated private pension plan is a pension plan that provides benefits to employees in “included employment” and is subject to the Pension Benefits Standards Act, 1985. “Included employment” means employment in connection with the operation of any work, undertaking or business that is subject to the legislative authority of the Government of Canada, such as banking, telecommunications, inter-provincial transportation etc.

Return to footnote 2