Retirement Compensation Arrangement (RCA) Confidential Questionnaire

ADVISOR INFORMATION

Name*

Company*

Telephone

Email*

SPONSORING COMPANY INFORMATION

Name of Sponsoring Company*

Date of Incorporation

Submitted as DD/MM/YYYY.

Corporate Year End

Submitted as DD/MM.

PLAN MEMBER

Plan Member Name*

Plan Member Date of Birth*

Submitted as DD/MM/YYYY

Plan Member Date of Hire*

Submitted as DD/MM/YYYY

Plan Member Province of Residence*

BEST THREE YEARS T4/T4PS EARNINGS

(DO NOT INCLUDE DIVIDENDS OR OTHER INCOME)

Year 1

Year 1 T4

Year 2

Year 2 T4

Year 3

Year 3 T4

You have not entered any earnings

Expected Age or Date of Retirement for Participant

Submitted as either an age (e.g. 65) or a date (e.g. Dec 31, 2021).

Please fill out either your expected age or date of your retirement. Do not respond to both questions.

If YES, type of plan:

Date of Entry into Plan

Submitted as DD/MM/YYYY.

PLAN MEMBER SPOUSE

(IF EMPLOYED BY THE COMPANY)

Plan Member Spouse Name

Plan Member Spouse Date of Birth

Submitted as DD/MM/YYYY.

Plan Member Spouse Date of Hire

Submitted as DD/MM/YYYY.

Plan Member Spouse Province of Residence*

BEST THREE YEARS T4/T4PS EARNINGS (SPOUSE)

(DO NOT INCLUDE DIVIDENDS OR OTHER INCOME)

Year 1

Year 1 T4 (spouse)

Year 2

Year 2 T4 (spouse)

Year 3

Year 3 T4 (spouse)

You have not entered any earnings

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