Form 12
Financial Hardship Application
Withdrawal from a LIRA or LIF
Finance and Treasury Board
For Staff Use Only Stamp
File no: Use this form to withdraw or transfer money from a locked-in retirement account (LIRA)
or a life income fund (LIF) because of financial hardship.
Answer the following questions to see if this is the right form for you.
Was the pension earned by you or your spouse while working in Nova Scotia?
Yes. Continue to the next question.
No. Do not use this form. Contact the jurisdiction where the pension was earned.
Was the pension earned while working for a company regulated by the federal government?
Yes. Do not use this form. Contact the financial institution that holds your locked-in account.
Check the FAQ on the OSFI website: www.osfi-bsif.gc.ca/Eng/pp-rr/faq/Pages/ulk-dbc.aspx
No. Continue to the next question.
Are you planning to withdraw at least $500?
Yes. Continue to the next question.
No. Do not complete this form. We cannot approve applications for less than $500.
What is your reason for withdrawing or transferring money from this account or fund?
The mortgage on my home—my principal residence—has not been paid AND I have received a
written demand for payment from the creditor which indicates I could face eviction if the debt is
not paid. Use this form if you have never had a withdrawal approved for this reason before.
The rent on my home–my principal residence–has not been paid AND I have received a written
demand from my landlord threatening eviction if the rent is not paid. Use this form if you have
never had a withdrawal approved for this reason before.
I, my spouse, or a dependent have medical expenses necessary to treat an illness or disability that aren’t
covered by any other program. Use this form if you have not had a withdrawal approved for that person’s
medical expenses for an application made in the past 12 months.
I expect to earn less than $35,733 (before taxes) over the next 12 months. Use this form if you have
not had a withdrawal approved for low income for an application made in the past 12 months.
Have you considered other effects of withdrawing or transferring this money?
• Your taxes. Contact the Canada Revenue Agency at 1-800-959-8281 to find out how your taxes
may be affected.
• Your eligibility for certain government benefits. Contact the government department or agency
that provides those benefits to see how they may be affected.
• Creditor protection. Money you withdraw is no longer protected from your creditors.
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Form 12 • 2015/01
1
G
Give your personal information
Last name:
First name: Middle name:
Address:
2
G
Postal code:
Email:
Phone number: Date of birth (dd/mm/yyyy):
Give information about your LIRA or LIF
LIRA or LIF account number: Name of financial institution: 3
G
Have you applied before to withdraw money for reasons of financial hardship?
Yes, I have applied before for reasons of financial hardship. Note that limits apply—see item 7 below.
No, this is my first such application.
4
G
Where was the money in the LIRA or LIF transferred from?
my pension plan with a former employer
a former spouse’s pension after the breakdown of our relationship
5
G
Where was the pension earned by you or your former spouse?
Company name:
Province of employment:
6
G
Attach a copy of the most recent statement from your LIRA or LIF
Statement attached.
7
G
Attach one or more of the following declarations and supporting documents
7A1 Withdrawal to cover Mortgage Arrears (see page 4)
Limit: Only one withdrawal for mortgage arrears allowed.
Do not use this form if a previous application was approved.
7A2 Withdrawal to cover Rental Arrears (see page 5)
Limit: Only one withdrawal for rental arrears allowed.
Do not use this form if a previous application was approved.
7B1 Withdrawal to cover Medical or Dental Expenses (see page 6)
7B2 Physician’s Statement and other supporting documents (see page 7)
Limit: one withdrawal every 12 months.
Do not use this form if an approval was given for a previous application made for that person in the
past 12 months.
7C Withdrawal because of Low Income (see page 8)
Limit: one withdrawal every 12 months.
Do not use this form if an approval was given for a previous application made in the past 12 months.
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Form 12 • 2015/01
8
G
Attach an Owner’s Certificate for the LIRA or LIF
Owner’s certificate attached, which is signed and witnessed. (see page 10)
9
G
Attach a Spouse’s Consent to the withdrawal or transfer, if needed
Spouse’s Consent attached, which is signed and witnessed. (see page 11)
I have no spouse as defined in the Pensions Benefit Act (see our definition of spouse on page 12)
10 G Sign the consent
To administer this application, we may need to share your personal information with your financial
institution. By signing this consent, you allow us to do that.
I consent to the use of the personal information that I provided with this application for the purpose of
administering the financial hardship provisions of the Pension Benefits Act only.
Name: Signature:
Date (dd/mm/yyyy):
It is an offence under the Criminal Code for anyone to knowingly make or use a false document with the intent that it be acted
upon as genuine.
This form is approved by the Superintendent of Pensions under the Pension Benefits Act.
11G Return the form and attachments
By mail to:
Finance and Treasury Board
Pension Regulation Division
PO Box 2531
Halifax, NS B3J 3N5
By fax to: (902) 424-1298
By courier to:
Finance and Treasury Board
Pension Regulation Division
1723 Hollis St, 4th floor
Halifax, NS B3J 1V9
Questions? Call 902-424-8915 or email [email protected]
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Form 12 • 2015/01
Form 12 • 7A1
Declaration in support of a withdrawal to cover
Mortgage Arrears
I declare that
• The mortgage on my home has not been paid.
• My financial institution has indicated I could face foreclosure on my principal residence,
the home where I normally live.
• I have not had a previous application for mortgage arrears approved by the Superintendent of
Pensions.
Declare the location of your principal residence
The same address given above in my personal information
or
The following address: Declare the amount you wish to withdraw $
• This amount must be at least $500.
• This amount cannot be greater than the mortgage payments that are in arrears and enforcement
costs that are owed at the time of the application.
• This amount cannot include any other money that is owed, like property taxes or insurance.
Attach a copy of the following document
The written demand for payment from the mortgage holder that sets out the amount you need to pay
both the mortgage debt in default on your home and all directly related enforcement costs to bring the
mortgage into good standing. The demand must also indicate that you could face foreclosure if the
debt is not paid.
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Form 12 • 2015/01
Form 12 • 7A2
Declaration in support of a withdrawal to cover
Rental Arrears
I declare that
• The rent on my principal residence has not been paid.
• I could face eviction on my principal residence, the home where I normally live.
• I have not had a previous application for rental arrears approved by the Superintendent of Pensions.
Declare the location of your principal residence
The same address given above in my personal information
or
The following address:
Declare the amount you wish to withdraw $
• This amount must be at least $500.
• This amount cannot be greater than the rental arrears and all directly related enforcement costs that
are owed at the time of the application.
• This amount cannot include any other money that is owed.
Attach a copy of the following document
The written demand for payment from your landlord that sets out the amount you need to pay both the
rental arrears and all directly related enforcement costs. The written demand must indicate you could
face eviction if the debt is not paid.
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Form 12 • 2015/01
Form 12 • 7B1
Declaration in support of a withdrawal to cover
Medical or Dental Expenses
I declare that
• These expenses are for medical or dental expenses that aren’t covered by any other program, like
insurance, a benefit plan, Pharmacare, or any other government program.
• These expenses are needed to treat an illness or disability.
• No approval has been given by the Superintendent of Pensions for a previous application for a
withdrawal to cover medical or dental expenses for that person made in the last 12 months.
Declare the amount you wish to withdraw $
• This amount must be at least $500.
• This amount cannot be more than the cost of all medical or dental expenses in the 12 months
before and the 12 months after the date of this application.
• Your doctor or dentist must identify the goods or services that are necessary to treat an illness or
disability.
• Estimated future costs must be based on written information from the provider of the goods or
services.
Declare who the medication or medical treatment is for
me, the owner of the LIRA or LIF
my spouse or dependent (as defined in definitions on page 12 of this form)
Spouse or Dependent Information:
Last name:
First name:
Middle name:
Attach receipts or estimates, or both
copies of receipts of all medical or dental expenses for the last 12 months
a written estimate of future costs for the next 12 months from the product or service provider
Attach one of the following statements about other coverage
a signed and dated statement listing any other coverage available to pay all or
part of the medical or dental expenses
a signed and dated statement confirming that no other coverage is available
Attach one of the following from your doctor or dentist
Note that if the medical or dental expenses are for a future period, the statement or letter must clearly state
the period for which the goods or services are required.
Physician or Dentist’s Statement, signed and completed by my doctor or dentist who is
licensed to practice medicine or dentistry in Canada (see page 7 of this form)
letter signed by my doctor or dentist stating that they are licensed to practice medicine or
dentistry in Canada and that the goods or services are necessary for the treatment of an illness
or disability
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Form 12 • 2015/01
Form 12 • 7B2
Physician’s Statement in support of the owner’s
Withdrawal to cover Medical or Dental Expenses
Use this form to give your opinion for the purposes of the owner’s application.
or
Give your opinion in another written format, such as a letter. The other format must
• state that you are a physician or dentist licensed to practice medicine or dentistry in a jurisdiction in
Canada
• state that, in your opinion, the patient requires specified goods or services necessary to treat an
illness or disability
• specify the goods or services that are necessary
• sign and date the letter
Physician or Dentist’s Information
Last name:
First name: Middle name:
Address:
Postal code:
Phone number: Physician or Dentist’s Statement
I am a physician or dentist licensed to practice medicine/dentistry in a jurisdiction in Canada. In my
opinion, my patient, (Print the name of your patient)
has an illness or physical disability and the following goods or services are or were necessary for my
patient’s treatment:
Signature :
Date (dd/mm/yyyy):
Time-sensitive material: This statement must be received by the Superintendent of Pensions within
12 months of signing to be valid.
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Form 12 • 2015/01
Form 12 • 7C
Declaration in support of a withdrawal
Because of Low Income
I declare that
• I expect to earn less than $35,733 (before taxes) over the next 12 months.
(Do not include income earned by family members.)
• I have not had an application for a withdrawal because of low income made in the last 12 months
approved by the Superintendent of Pensions.
Calculate your Expected Income for the next 12 months
Part-time or Full-time work (gross income before taxes/deductions):
$
Employment Insurance (EI)
$
Canada Pension Plan (regular or disability):
$
OAS/GIS/other pensions
$
Social Assistance:
$
LIF Income:
$
Workers’ Compensation Income:
$
Self-Employment/Business Income
$
Other (specify):
$
Total Expected Income
A
$
0
Calculate the maximum amount you can unlock due to low income in a 12-month period
Is your Total Expected Income (A) more than $35,733?
Yes. You are not eligible to withdraw any funds.
No. Use your Total Expected Income (A).
Total Expected Income A
Subtract B from $26,800 =
multiply by 0.75 = B
$
$ 0.00
$ 26,800.00
Maximum that you can unlock
Identify the amount you wish to withdraw
I want to withdraw the maximum allowed.
or
$
(This amount must be at least $500.)
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Form 12 • 2015/01
Attach your most recent Notice of Assessment (NOA) or equivalent document
issued by the Canada Revenue Agency
attached (required) . If you don’t have a NOA, sign up for an epass at
cra-arc.gc.ca/myaccount to access your NOA.
Call Canada Revenue Agency at 1-800-959-8281 to request an NOA or an equivalent document.
Attach other documents that confirm your income
Employment Insurance Statement with benefit amount, end date of benefits, and number of eligible
weeks
Canada Pension Plan statement
Social Assistance benefits statement or cheque stub
Workers Compensation benefits statement or cheque stub
Record of Employment (ROE)
Last 3 consecutive pay stubs for all part-time or full-time employment
Long-term or short-term disability statement
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Form 12 • 2015/01
Form 12 • 8
Owner’s Certificate
I certify that I own the LIRA or LIF named in this application and am applying to withdraw or transfer
money from it.
I certify that on the date I sign this statement: (Check only one box.)
I do not have a spouse.
I have attached my spouse’s consent to the withdrawal of money from my LIRA or LIF—Spousal
Consent, page 8 of this form.
I have a spouse, but we do not live together now and do not intend to live together again in the
future, and my spouse is not entitled to any part of the money in the LIRA or LIF because of a court
order or domestic contract.
I have a spouse but all the money in my LIRA or LIF was originally earned by my former spouse
under his or her pension plan, and I became the owner of that money as a result of the breakdown
of our relationship.
I certify that all of the information in this application is true and complete.
I understand that, in addition to the amount that I have applied to withdraw or transfer from my LIRA or LIF,
applicable taxes and an application fee of $116.65 will be withheld.
I understand that any money withdrawn or transferred from my LIRA or LIF will no longer be protected from
my creditors.
I understand that it is a criminal offence under the Criminal Code of Canada for anyone to knowingly make
or use a false document with the intent that it be acted on as genuine.
Signature (Owner):
Date (dd/mm/yyyy):
Witnessed by:
Date (dd/mm/yyyy):
This certificate must be signed before a witness. Your witness
• must be at least 18 years of age
• must see you sign the form
• must sign, print their name, and date this form immediately after seeing you sign and date this form
Witness’ Information
Last name:
First name: Middle name:
Address:
Postal code:
Phone number: Time-sensitive material: This application must be received by the Superintendent of Pensions within
60 days of signing to be valid.
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Form 12 • 2015/01
Form 12 • 9
Spouse’s Consent to the Withdrawal or Transfer of Money
To be completed by the spouse referred to in the Owner’s Certificate portion this application. Before
signing this consent, you should speak to a lawyer about your rights and the legal consequences of signing
this consent.
Spouse’s Information
Last name:
First name: Middle name:
Address:
Postal code:
Phone number: Spouse’s Consent
I am the spouse of the owner of the LIRA or LIF identified in this application.
I understand that the owner is applying to withdraw or transfer money from the LIRA or LIF
named in this application.
I understand that the owner must have my consent to withdraw or transfer the money from the LIRA or LIF.
I understand that I do not have to give my consent—it is my choice to consent or not to consent.
I understand that while this money is kept in the LIRA or LIF, I may have a right to a share of
this money if our relationship breaks down or if the owner dies.
I understand that when money is withdrawn or transferred from the LIRA or LIF, I may lose any right that I
have to a share of the money that is withdrawn of transferred.
I consent to the owner’s application to withdraw or transfer money from the LIRA or LIF.
I give my consent by signing and dating this consent in the presence of a witness.
Signature (Spouse):
Date (dd/mm/yyyy):
Witnessed by:
Date (dd/mm/yyyy):
This consent must be signed before a witness. Your witness may not be your spouse (the owner). Your
witness must be at least 18 years of age. Your witness must see you sign the form. Your witness must
sign, print their name, and date this form immediately after seeing you sign and date this form.
Witness’ Information
Last name:
First name: Middle name:
Address:
Postal code:
Phone number: Time-sensitive material: This application must be received by the Superintendent of Pensions within
60 days of signing to be valid.
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Form 12 • 2015/01
How we define spouse, dependent, and domestic contract
Spouse
• The person you are married to.
• The person you are married to, if the marriage hasn’t been legally ended.
• The person you thought you were married to, if you are still living together.
• The person you thought you were married to, if you have lived together within the last 12 months.
• The person you are living with as a registered domestic partner under the Vital Statistics Act.
• The person you have been living with in a sexual relationship for at least one year, if neither of you
are married to someone else.
• The person you have been living with in a sexual relationship for at least three years, even if one or
both of you are married to someone else.
Dependent
A dependent is one of the following who is dependent on you or your spouse for support at the time this
application is signed or in the 12 months before it is signed:
•
•
•
•
•
a child, stepchild, grandchild
a parent, step-parent, or grandparent
a brother, half-brother, or step-brother
a sister, half-sister, or step-sister
an uncle, aunt, niece, or nephew
Domestic contract
A domestic contract means
• a written agreement that provides for a division between spouses of a pension benefit, deferred
pension, or pension
• a marriage contract as defined in the Matrimonial Property Act
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Form 12 • 2015/01