PERSON ID

20702556

Public Service Pension Plan
PO Box 9460
Victoria BC V8W 9V8

Web pspp.pensionsbc.ca
Toll-free 1-800-665-3554 (Canada/U.S.)

AA Public Service FORMER SPOUSAL
XJ. Pension Plan RELATIONSHIP
DECLARATION

Instructions for plan member — Mark Thomas Holand

You must complete this form if you are taking your benefit out of the plan. We cannot process payment of your
pension benefit until we have received this form.
1. Read the explanation of former spouse entitlement below.
2. Complete and sign the form. (You must do this whether or not you have a spouse with entitlement.)
3. If you have a separation agreement or registered court order with a former spouse that discusses your
benefits in the Public Service Pension Plan will be treated, include a clear copy of that document.
4. Submit the form and any accompanying documents to the Public Service Pension Plan.

Note: If you have a former spouse with entitlement, your benefit payment options and amounts may be affected.
Once we have received your documents, we will inform you of any changes.

Explanation of former spouse entitlement

Your pension is a type of family property.

If you were married (or in a long-term common-law relationship) with someone while you were contributing to
the pension plan, they are legally entitled to a portion of your benefit. If you formally divorced or separated,
you may have a legal agreement (separation agreement or registered court order) that describes how your
pension benefits will be distributed. If you need more help determining whether you have a former spouse
with entitlement, visit pspp.pensionsbc.ca/divorce- and- separation.

FORMER SPOUSAL RELATIONSHIP DECLARATION

Note: This form asks you to declare whether you have a former spouse who is entitled to a portion of your
pension. Do not provide information about your current spouse on this form.

| declare that [| | do NS |!do not have a former spouse who is entitled to a portion of my pension benefits.

FORMER SPOUSE LAST NAME (if applicable) FORMER SPOUSE FIRST NAME (if applicable)

PLAN ME R SIGNATURE DATE SIGNED YYYY-MM-DD

X 2016-07-23

Freedom of Information and Protection of Privacy Act - The personal information on this form is collected under the authority of the Public Sector Pension Plans Act
and will be used by the BC Pension Corporation to administer a plan member's pension and other non-pension benefits. If you have any questions about the
collection and use of this information, contact the privacy officer at PO Box 9460, Victoria BC V8W 9V8 or by telephone at 250-387-1002.

British Columbia Pension Corporation is the administrative agent of the Public Service Pension Plan

Return original to the pension plan. Make a copy for your records.
PC/PSPP 2006-043 (Page 11) 2024 02.02 2026-07-22 13:35:51