FORM 4:  Request by Limited Member for Transfer or Pension
Family Relations Act, section 74 

(Note: This form is for use in relation to an unmatured pension in a defined benefit Plan.)
___________________________________________________________________________________

          To:    Administrator of pension plan 

          Name of Plan:      _______________________________________________

          Address of Plan:   _______________________________________________

          (please print)     _______________________________________________

______________________________________________________________________________

          From:    Spouse of member (Note:  "spouse"  includes a former spouse.)

          Name:             _______________________________________________

          Address:          _______________________________________________

          Telephone: (home) ________________  (work) __________________

          Social Insurance No.: ___________________  Date of Birth: __________________

______________________________________________________________________________

          In relation to:     Plan member 

          Name of member:   _______________________________________________

          Address:          _______________________________________________

                            _______________________________________________

          Telephone: (home) __________________  (work) ________________

          Social Insurance or Pension Plan Identity Number: ____________________

          Employer:         _______________________________________________

_______________________________________________________________________

Request:
As the limited member named above, I request: (check the applicable request)
                    
[ ]  that you

     (a)  transfer my share of the member's pension value by a transfer that is
          permitted under section 33 (2) of the Pension Benefits Standards Act, and

     (b)  advise me in writing of the information that you require in
          order to do this.
          +(Note: This option is only available if the member is eligible to retire
            but has not retired.)

[ ]  that you provide me with a separate pension from the plan when the member retires.


          ________________________________________     __________________________
                           Signed (Limited Member)                           Date

          ________________________________________
          Signed (Witness to signature of Limited Member)
          
          Name of Witness:    ___________________________________________________

          Address of Witness: ___________________________________________________