1. Any application for a statement referred to in section 63.1 of the Act respecting the Pension Plan of Elected Municipal Officers (chapter R-9.3) must contain the following information and be accompanied by the following documents:
(1) the name, address, social insurance number and date of birth of the council member or former council member and of his spouse;
(2) a marriage certificate and, where applicable, the date on which the spouses resumed living together;
(3) confirmation in writing from a certified mediator to the effect that he has obtained a family mediation mandate, or a copy of the application for separation from bed and board, divorce, annulment of marriage or payment of a compensatory allowance or, where applicable, a copy of the judgment ruling on such an application;
(4) the information that must be provided by the employer in his annual report, in accordance with section 188 of the Act respecting the Government and Public Employees Retirement Plan (chapter R-10), for the year during which the assessment is determined up to the date set for that assessment, as well as for the previous year; that information must be certified by an authorized representative of the employer.