DECLARATION OF THE MEMBER OR PURCHASER
(1) that the total of the locked-in amounts credited to my account in the following retirement savings instruments:
(a) defined contribution pension plans;
(b) defined benefit or defined benefit-defined contribution pension plans in application of provisions similar to those of a defined contribution plan;
(c) life income funds;
(d) locked-in retirement accounts;
(e) registered retirement savings plans of which the balance must be converted into a life annuity (locked-in RRSPs);
(f) the voluntary retirement savings plans governed by the Voluntary Retirement Savings Plans Act (chapter R-17.0.1),
(2) that the total is based on the most recent information that I have;
(3) that the said information is less than 18 months old.
NOTE: Whosoever makes a false declaration with the intention of obtaining a lump-sum payment payable under a retirement savings instrument mentioned in the declaration is subject to the penalties provided for in sections 257 and 262 of the Supplemental Pension Plans Act (chapter R-15.1).