FSCO Family Law Form 1A - Plan Administrator Request for

Financial Services
Commission
of Ontario
Plan Administrator Request for
Information/Payment of Fee
FSCO Family Law Form 1A
(Optional Form)
Approved by the Superintendent of Financial Services pursuant to
the Pension Benefits Act, R.S.O. 1990, c. P.8.
This is an optional form that may be used by the pension plan administrator (Plan Administrator) to ask for missing or
incomplete information, or for payment of the required fee (if any). This form may be used as of January 1, 2013, and must
be used as of July 1, 2013.
The Plan Administrator will not provide the Family Law Value until the application is complete and accompanied by all
required documents and the fee (if any). The “Family Law Value” means the “imputed value” under the Ontario Pension
Benefits Act.
Once the Plan Administrator receives your complete application, including all required documents and the fee (if any), you
and your spouse/former spouse will receive a Statement of Family Law Value (FSCO Family Law Form 4) from the Plan
Administrator within 60 days. This 60 day period will start from the day the Plan Administrator receives your complete
application.
Part A
Applicant Information
Last Name
First Name and Initials
Mailing Address (Street Number and Name)
Apt./Unit
City
Province
Postal Code
Telephone Number (Main)
Telephone Number (Other)
Fax Number
(
(
(
)
)
)
Part B
Pension Plan Information
Name of Pension Plan
Pension Plan Registration Number
Plan Administrator
Name of Employer/Union
Mailing Address (Street Number and Name)
Suite/Floor No.
City
Province
Postal Code
Telephone Number
Fax Number
Website Address (if available)
(
(
)
)
For Plan
Administrator
Use
Effective (2013-01-01)
FSCO (1265E.2)
© Queen's Printer for Ontario, 2013
FSCO Family Law Form 1A
Page 1 of 3
PRINT
RESET
SAVE
Part C
Missing/Incomplete Information
N/A
You have not provided the Plan Administrator sufficient information to calculate the Family Law Value. If you want to receive
your Statement of Family Law Value (FSCO Family Law Form 4), you must provide the following:
Application for Family Law Value (FSCO Family Law Form 1)
Proof of Plan Member’s date of birth (see Part C of the User Guide for FSCO Family Law Form 1)
Proof of date of birth of spouse/former spouse of the Plan Member (see Part D of the User Guide for FSCO Family Law Form 1)
Proof of starting date of your spousal relationship (see Part E of the User Guide for FSCO Family Law Form 1)
Proof of your separation date (Family Law Valuation Date) (see Part F of the User Guide for FSCO Family Law Form 1)
Other required information [e.g. incomplete Application for Family Law Value (FSCO Family Law Form 1), etc.] as indicated
below
For Plan
Administrator
Use
Effective (2013-01-01)
FSCO (1265E.2)
© Queen's Printer for Ontario, 2013
PRINT
RESET
SAVE
FSCO Family Law Form 1A
Page 2 of 3
Part D
Missing Fee Payment
N/A
The type of benefits accrued by the Plan Member under the pension plan [which determines the maximum fee payable to
obtain a Statement of Family Law Value (FSCO Family Law Form 4)] is:
combination of a defined benefit and a defined contribution benefit
greater of a defined benefit and a defined contribution benefit
defined benefit
defined contribution benefit
The Plan Administrator’s fee for your Statement of Family Law Value (FSCO Family Law Form 4) is:
$
Your payment may be made by:
personal cheque payable to
certified cheque/bank draft payable to
money order payable to
other
Send your payment to:
Plan Administrator
c/o
Mailing Address (Street Number and Name)
Suite/Floor No.
City
Province
Postal Code
NOTE:
The maximum fee that a Plan Administrator may charge for providing a Statement of Family Law Value (FSCO Family Law Form 4) is:
$200
If the pension plan provides a defined contribution benefit to the Plan Member.
$600
If the pension plan provides a defined benefit to the Plan Member.
$800
If the pension plan provides a combination of a defined benefit and a defined contribution benefit or a benefit
that is the greater of a defined benefit and a defined contribution benefit to the Plan Member.
If the Plan Member and the spouse/former spouse of the Plan Member requested two Family Law Values under Appendix A of Application
for Family Law Value (FSCO Family Law Form 1) the maximum fee that the Plan Administrator may charge is double the applicable
amount shown above.
Signature of Plan Administrator or Plan Administrator’s
authorized agent or representative
Name of Plan Administrator or Plan Administrator’s
authorized agent or representative (printed)
Dated (yyyy/mm/dd)
For Plan
Administrator
Use
Effective (2013-01-01)
FSCO (1265E.2)
© Queen's Printer for Ontario, 2013
PRINT
RESET
SAVE
FSCO Family Law Form 1A
Page 3 of 3