1000 - 1801 Hamilton Street
REGINA, SK S4P 4W3
Phone: 306-787-5442
Fax: 306-787-0244
Toll free: 1-877-275-7377
E-mail: [email protected]
Common-law Spouse Declaration to be Completed Upon the Member’s Death
This declaration is to be completed after the death of a member of the Public Employees Pension Plan, where a claim is being made by a common-law spouse
and there is no common-law declaration on file.
This form is designed based on Saskatchewan legislation. Please contact PEPP if you are or were working outside Saskatchewan as your pension may be subject to
the legislation of another province.
SECTION A: DECEASED MEMBER INFORMATION (Please print)
Last Name
First Name and Initial
Date of Death (day/month/year)
SECTION B: DECLARANTS INFORMATION
Last Name
First Name and Initial
Mailing Address
City
Birthdate (day/month/year)
Province
Postal Code
SECTION C: DECLARATIONJ
I, of in the
(Declarant’s Name)
(City, Town, Village)
province of , country of
DO SOLEMNLY DECLARE, that I am not legally married and that and I
(Deceased’s Name)
cohabited in a conjugal relationship for , 20
continuous year(s) from to ,
.
SECTION D: SUPPORTING INFORMATION
1.
3.
4.
5.
6.
Legal Family Name
Yes
If yes, please complete the table below.
If more space is required use the back of this page.
(This would include adopted children or children of one spouse to whom the other acted as a parent)
Given Name
2.
No
There were children of the common-law union.
Family Name Commonly Used
My common-law spouse and I:
a. Jointly signed a residential lease, mortgage or purchase agreement
relating to a residence in which we both lived.
b. Jointly owned property other than our residence.
c. Had joint bank, trust, credit union or charge card accounts.
I had life insurance on myself which named my common-law spouse or my
child(ren) as beneficiary(ies).
My common-law spouse had life insurance on himself/herself which
named me or my child(ren) as beneficiary(ies).
If none of the above sections apply, what other documentation are you
aware of that would indicate your common-law relationship?
Date of Birth
No
Yes
No
No
No
Yes
Yes
Yes
No
Yes
Please provide the names of at least two disinterested parties who know of the common-law relationship
for the time period stated.
Name
Relationship
Address
I make this Solemn Declaration conscientiously believing it to be true and knowing that it is of
the same force and effect as if made under oath and by virtue of the Canada Evidence Act.
Signature of Declarant
Declared before me at the city/town/village of in the
province of , country of
this
day of , 20
.
Signature of Notary Public/Justice of the Peace/Commisioner for Oaths
Print Name
Phone Number
Commissioner for Oaths in and for Saskatchewan whose appointment expires
June 2015