DECLARATION OF THE PURCHASER
I declare:
(1) that I am not a party to any contract establishing a locked-in retirement account or a registered retirement pension plan of which the balance must be converted into a life annuity (locked-in RRSP);
(2) that the amount that I have determined or intend to determine as the maximum temporary income for the current fiscal year is, for each of my life income funds and the locked-in accounts of my voluntary retirement savings plans governed by the Voluntary Retirement Savings Plans Act (chapter R-17.0.1) and offering temporary variable payments, at least equal to the reference temporary income calculated for this fund.
__________(Date)__________ __________(Signature)__________
NOTE: Whosoever makes a false declaration with the intention of obtaining a temporary income payable from the life income fund 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).