UNCLASSIFIED
Standardized Termination Report for DC Pension Plans
(Please refer to the Instruction Guide for Filing and Reporting Requirements for Defined Contribution Pension Plan Terminationswhile completing this form)
The Pension Benefits Standards Act, 1985 (PBSA) requires aplan administrator to inform the Office of the Superintendent of Financial Institutions (OSFI),in writing, of an upcoming plan termination (in whole or in part) at least 60 days before the effective date of the termination.
Name of Pension Plan (the Plan):
Registration Nos.OSFI Canada Revenue Agency
1)Effective date of termination:
Day Month Year
2)Date members were informed of the Plan termination:
Day Month Year
3)Date members were provided with their detailed member statements:
Day Month Year
If this date is not within 30 days of the plan termination date, complete part a).
a) Explanation:
Statements will be sent by: Day Month Year
4)Have all employer and employee requiredcontributions been remitted to the Plan up to the termination date?
Yes No
5)Are all member accounts vested?
Yes No
6)Total number of members affected by the termination:
7)If any affected members are outside of the jurisdiction of the PBSA, do the benefits of these members comply with the provisions of that legislation?
YesThe other jurisdictions are:
No
N/A
8)Market value of Plan assets as at the Plantermination date:
Assets $
9)Total value of members’ accountsas at the Plan termination date:
Member accounts $
10)Were there any forfeitures (excess assets) at the date of termination?
Yes No
Forfeitures will be distributed as follows:
11)Is there a continuing pension plan for Plan members?
Yes No
If yes, registration number and jurisdiction:
12Is the detailed member information attached to this Standardized Report?(See point 12 of Section III of the Instruction Guide)
Yes No
13Transfer Options for members(in compliance with Section 26 of the PBSA):
Cash refund of non-locked-in benefits
Another pension plan
Life Income Fund
Locked-in Registered Retirement Savings Plan[1]
Immediateannuity
Deferred annuity
Required documents attached:
Annual Information Return as at the date of termination (fully terminated plans only)
Member information including account balances (See point 12 of Section III of the Instruction Guide)
Sample of the termination statement provided to members
Executed plan amendment, board resolution or letter indicating the Plan has terminated (as required by the Plan text)
This report has been prepared by[2]:
Please printSignature
Title or Position and Company
Date
Contact person information:
Name of contact
Address
City
Province/State/Country Postal Code
Telephone Fax
1/2
[1] Transfers to Locked-in Retirement Accounts (LIRA) are not permitted under the PBSA
[2] Pursuant to section 24 of the PBSR, the report in respect of a defined contribution plan may be prepared by an actuary, accountant or other professional advisor.