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

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hardship unlocking provisions of the Pension Benefit Standards Regulations, 1985 (PBSR) allow for funds to be withdrawn based on one of the following or a combination of both:

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 plan^{Footnote 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

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 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

Enter the amount that is 50% of the YMPE for the current calendar year. For 2024, this amount is $34,250 (the YMPE in 2024 is $68,500).

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

If your expected income is over 75 % of the YMPE (i.e. $51,375 in 2024), 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

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

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

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.

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Form 1

Attestation reagrding 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

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.