TERMINATION SELECTION STATEMENT continued for
Mark Thomas Holand EB | 20702 556

PAYMENT DIRECTION

Instructions for plan member

e Complete this form if you are choosing Option: Payment of Commuted Value of Pension

* Have the financial institution or registered pension plan (RPP) to which you are transferring your locked-in funds
complete and sign the locked-in agreement below.

* You may transfer your funds to only one financial institution or RPP. Your RPP must agree to accept these funds.
Do not use this form if you are requesting a reciprocal transfer.

Select | -in arrangement for your locked-in funds (check one).
ocked-in retirement account (LIRA)

[_] Locked-in life income fund (LIF)

[_] An insurance company to purchase deferred life annuity

[_] Registered pension plan (RPP) of my new employer ** (select one)
[_] defined contribution
[_] defined benefit

"* If selected, and your RPP is a defined benefit plan, the entire commuted value of both the locked-in portion and the
registered cash payment portion must be transferred to your RPP.

This section to be completed by the financial institution or registered pension plan to which your locked- in funds are
being transferred.

Instructions for financial institution
For LIF and LIRA transfers:

If the locked-in funds are being transferred directly to an authorized issuer listed on the Superintendent's List of Financial
Institutions Offering Locked- In Pension Products (available on the BC Financial Services Authority's website at bcfsa.ca)
complete the name and contact information for the issuer below.

~ If the locked-in funds are being transferred to an agent acting on behalf of an authorized issuer (as listed on the above-
mentioned list) complete the name of both the issuer and the agent, and provide the contact information for the agent.

© If the recipient financial institution is an agent authorized to act on behalf of an issuer, provide documentation that
demonstrates this authorization, and the relationship between the agent and the issuer.

~ Payment will not be made to an issuer that does not appear on the above-mentioned list or to an agent of an authorized
issuer that does not provide the above-mentioned documentation.

- For the purchase of a deferred life annuity, complete the name and contact information for the insurance company below.
Instructions for registered pension plan (RPP)

Record the Canada Revenue Agency (CRA) registration number for RPP (do not fill in an agent name). If the registration
number for RPP is not provided, the benefit transfer may be delayed.
Definitions

“Agent” means a financial institution or other entity that has been delegated legal authority by an authorized issuer to offer
and accept locked-in funds on behalf of the authorized issuer.

“Issuer” means a financial institution that is listed on the BC Superintendent of Pensions' list of financial institutions
authorized to issue LIRAs or LIFs. The Superintendent's List of Financial Institutions Offering Locked- In Pension Products
is available on the BC Financial Services Authority's website at bcfsa.ca.

"Officer" means an individual who has legal authority to act on behalf of an issuer or an agent.
- For assistance or questions about completing this section, contact the Public Service Pension Planat 1-800-665-3554.

NAME OF AUTHORIZED ISSUER, RPP OR INSURANCE COMPANY (lo which the locked- in funds will be paid) \[/} !f authorized issuer: Check to venfy
inclusion on the Superintendent's List of

a Financial Institutions Offenng Locked-In
' Pension Products
(A [Jan
NAME OF AGENT OF AUTHORIZED ISSUER (if completed, locked- in funds will be payable to agent) [_] Staning officer for agent: Have you

provided documentation that demonstrates
(1) the agent is authorized to act on behalf
of an issuer and (2) the relationship
between the agent and the issuer

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

PC/PSPP 2006-043 (Page 9) 2024 02 02 2026-07-22 13:35:51