FORM 2: Request for Designation as Limited Member of Pension Plan Family Relations Act, section 72 (Note: This form is for use in relation to * a matured pension; * an unmatured pension in a defined benefit plan; * an agreement under s. 80(2) of the Family Relations Act.) ______________________________________________________________________________ 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: * 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 I be designated as a limited member of your pension plan. (If the pension is matured on the date of this request, this will also act as a request for the Plan to administer a benefit split of the pension in accordance with s. 76 (1) 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.