TERMINATION SELECTION STATEMENT continued for
Mark Thomas Holand 20702556
FINANCIAL INSTITUTION ADDRESS

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C - PROVINCE POSTAL CODE
Now Westman ster BO 3L 3C|
INDIVIDUAL ACCOUNT NO. CRA REGISTRATION NO. (RPP only)
260 6
CONTACT NAME CONTACT PHONE NUMBER CONTACT EMAIL ADDRESS
Ni V~Vaw ni Yar 0044 oF 3OS4 hivanm - Shi vam (a oteVa Lie!
f- () 9 Orr

By signing below, | confirm that | have been advised in writing that the locked-in funds being transferred, whether to a locked-in
retirement account (LIRA), to a locked-in life income fund (LIF), to a registered pension plan (RPP) or toward the purchase of a
deferred life annuity, is locked-in money subject to the locking-in provisions of the British Columbia Pension Benefits Standards
Act. Also, if transferring to a LIRA or LIF, | certify that | am an officer or agent of the above-named financial institution and that the
issuer is on the Superintendent of Pensions' list of financial institutions authorized to issue LIRAs or LIFS.

AUTHORIZED SIGNING OFFICER (print name) AUTHORIZED SIGNING OFFICER SIGNATURE DATE SIGNED YYYY-MM-DD

S hivasa SHAM X 2oL 6 — OF-223

The portion in excess of the /ncome Tax Act limit is payable in cash only (the Public Service Pension Plan will deduct income tax).

By signing below, | understand that | am selecting Option 2 as my benefit:

| have completed the former spousal relationship declaration page and | certify that the information on this statement is, to the
best of my knowledge, correct and complete.

DATE SIGNED YYYY-MM-DD

PLAN MEMBER SIGNATURE

MAILING ADDRESS (print and include street, city or town, province and postal code)

| = [G ft Ne St Le West minster fC VFC ODF %

MAILING ADDRESS |S (check one) | IF TEMPORARY PHONE (include 10 digits) EMAIL ADDRESS
si PERMANENT START DATE:

A er / d & é
[__] TEMPORARY END DATE: 2-36 : $F 76 Mh is t h o (an ge

elon

Please note that before we can finalize your benefit, we will require a clear copy of your proof of age or identity.

Plan Member: Return this completed page to the pension plan, if applicable.

PC/PSPP 2006-043 (Page 10) 2024.02.02 2026-07-22 13:35:51