FORM 5:  Request in relation to a Matured Pension Divided under an Agreement or Court Order
Made Before July 1, 1995

* for Designation as Limited Member, and
* for Payment of Benefits

Family Relations Act, section 76 (4)
_____________________________________________________________________________

          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:         _______________________________________________

______________________________________________________________________________

Other required information:  

Other required information:  

* Date of marriage ___________________________

* Entitlement Date+ for Spouse: ____________________________

+(Note: This is the date on which the spouse became entitled to an
interest in the member's pension in accordance with s. 56 (1) of the
Family Relations Act (see below).)

* A copy of the separation agreement or court order on which the entitlement date is based++
++(Note: to be attached to or enclosed with this Form.)

______________________________________________________________________________

Request:   I request that

     (a)  I be designated as a limited member of your pension Plan, and

     (b)  you administer the division of the member's matured pension by providing me with
     separate payment of benefits in accordance with s. 76 (4) of the Family Relations Act.


     _________________________________________      ______________________________
                               Signed (Spouse)                                Date 

     _________________________________________
       Signed (Witness to signature of Spouse)

     Name of Witness:____________________________________________

     Address of Witness: __________________________________________

_____________________________________________________________________________

Family Relations Act, section 56: 
(1)  Subject to this Part and Part 6, each spouse is entitled to an interest in each family asset on or after March 31, 1979, when  
(a) a separation agreement,
(b) a declaratory judgment under section 57, 
(c) an order for dissolution of marriage or judicial separation, or
(d) an order declaring the marriage null and void 
respecting the marriage  is first made.