Spousal Waiver of Survivor Benefit
Entitlement – Limited Life Expectancy
OPSEU Pension Trust 1 Adelaide Street East, Suite 1200, Toronto, Ontario M5C 3A7
Telephone: 416-681-6100 Toll-free: 1-800-637-0024 Fax: 416-681-6175 www.optrust.com
INSTRUCTIONS
This statement must be completed and delivered to OPTrust. Before completing the statement, each party should consider
obtaining independent legal advice concerning their individual rights and benefit entitlements.
Part 1 is to be completed by the member, former member or retired member of the OPSEU Pension Plan, who is applying
for the lump sum payment of all the commuted value of his or her pension entitlement, due to a shortened life expectancy
of less than two years.
If applicable, Part 2 is to be completed by the “spouse”, as defined in the OPSEU Pension Plan, of the individual who is
identified in Part 1.
PART 1
OPTrust ID Number
I,
(Former) Member’s Name
declare the following to be accurate, complete and true statements:
• I have an illness or physical disability that is likely to shorten my life expectancy to less than two years:
• I am a member of the Plan:
Current
Former
Yes
No
Retired
Youngest child’s date of birth: (D D / MM/ Y Y Y Y )
• I have children as defined in the Plan, under “child”:
Yes
• I have a “spouse”, as defined in the Plan:
No
• My marital status is:
Single
Yes
Married
D
D
Common-law
M
M
Separated
Y
• I am living separate and apart from my “spouse”, as defined in the Plan:
Yes
No
• My pension entitlement is subject to an order under the Family Law Act
or the provisions of a domestic contract or family arbitration award:
Yes
No
Y
Y
No
Y
Divorced
Widowed
Please complete this section ONLY if you are receiving a monthly OPTrust pension. When my first pension payment was due:
• I had a “spouse”, as defined in the Plan:
Yes
• I was living separate and apart from my spouse:
No
Yes
No
• A waiver of entitlement to a joint and survivor pension was in effect:
Yes
No
This waiver must be accompanied by an OPTrust 3003 “Medical Examination Report.”
I understand that there will be no further benefits payable to me, my spouse, my beneficiaries or my estate from the
OPSEU Pension Plan whether or not I outlive the medical expectations. I further understand and agree to discharge, waive
and forever relinquish any and all actions or causes of action that I may have or have had, whether past, present or future,
whether known or unknown and whether anticipated or unanticipated by me. This waiver will be binding on me, my
spouse, my heirs, my personal representatives, and my assignees.
Signature of (Former) Member
Date (D D / MM/ Y Y Y Y )
x Signature of (Former) Member
Signature of witness
D
D
M
M
Y
Y
Y
Y
Name of witness
x Signature of witness
OPTrust 3006 (11/12)
Keep a copy of this form for your records.
Continued on next page >
PART 2
As the spouse of the member, former member or retired member who is applying for a limited life expectancy benefit,
you are not obligated to sign this statement. You should seek advice from a lawyer about your rights and the legal
consequences of signing the consent.
I am the spouse of the member/former member/retired member identified in Part 1 of this form.
I understand that:
• t he member/former member/retired member is applying for a limited life expectancy benefit from OPTrust
• the member/former member/retired member cannot receive the payment without my consent
• I am not required to give my consent
• a s long as the funds remain with OPTrust, I may have a right to a spousal pension if our relationship ends or if the
member/former member/retired member dies
• if funds are withdrawn from OPTrust through the limited life expectancy provision:
– I will lose any right I have to a spousal pension or any other benefits from the OPSEU Pension Plan, whether or not the member/former member/retired member outlives the medical expectations, and
– a ny other beneficiaries will lose any right to OPSEU Pension Plan benefits, whether or not the member/former member/retired member outlives the medical expectations.
By signing and dating this form, I consent to the member’s/former member’s/retired member’s application for payment of a
limited life expectancy benefit. I further understand and agree to discharge, waive and forever relinquish any and all actions
or causes of action that I may have or have had, whether past, present or future, whether known or unknown and whether
anticipated or unanticipated by me. This waiver will be binding on me, my spouse, my heirs, my personal representatives,
and my assignees.
Date of birth: (D D / MM/ Y Y Y Y )
I,
Spouse of (Former) Member’s Name
D
D
M
M
Y
Y
Y
Y
declare the following to be accurate, complete and true statements:
• I am the “spouse” of the individual named in Part 1, i.e. (former) member.
Yes
No
• I consent to the withdrawal of the lump sum payment of all the commuted value of the
pension entitlement resulting from the (former) member’s membership in the Plan.
Yes
No
Yes
• I understand that if I sign this waiver, I will not be paid any pre-retirement death benefit.
No
Please complete this section ONLY if the former member is receiving a monthly OPTrust pension. When the first pension
payment was due:
• I was the “spouse”, as defined in the Plan.
Yes
No
• I consent to the withdrawal of the lump sum payment of all the commuted value
of the pension entitlement resulting from the (former) member’s membership in the Plan.
Yes
No
• I understand that if I sign this waiver, I will not be entitled to any joint and survivor pension.
Signature of (Former) Member’s Spouse
No
Date (D D / MM/ Y Y Y Y )
x Signature of (Former) Member’s Spouse
Signature of witness
Yes
D
D
M
M
Y
Y
Y
Y
Name of witness
x Signature of witness
Note: OPTrust must receive this document within 60 days of its signing, otherwise it will be considered null and void.
OPTrust 3006 (11/12)
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