Mark Holand
June 30, 2026

Page 3

Retirement or pension
benefits from Public
Service Pension Plan

Automobile insurance or
other payments from a
third party as a result of
this disability

INCOME DECLARATION
PID # 130684485

Name: Mark Holand

Group Plan Number: (51295 (LTD)/51296 (IC)/51292 (STD)

1.

| agree to notify and provide proof to Canada Life of any reportable income that:

a) | receive or become entitled to; or

b) A member of my family receives or becomes entitled to, as a result of my disability, for or
during the period of my disability claim.

| agree to provide this notice and proof within 30 days after the income is first received or

awarded.

| recognize and accept my obligation to repay any benefits that are overpaid according to the

terms of group plan number 51296 as aresult of my entitlement to other income. | agree to

repay such amounts immediately after | am notified of an overpayment.

July 2, 2026

Signature Date