DECLARATION OF THE PURCHASER
(1) that the income whose payment I shall receive during the next 12 months, other than the temporary income of which I am applying for payment from the life income fund with respect to which I am making this declaration, is $_______________;
(2) that I am not a party to any other contract establishing a life income fund;
(3) that a total of $_______________ has been paid to me during the current year from the life income funds to which I have been party, other than the one with respect to which I am making this declaration, and that the said total included $_______________ that was paid to me in the form of a temporary income.
NOTE: Whosoever makes a false declaration with the intention of obtaining a temporary income payable from the life income fund mentioned in the declaration is subject to the penalties provided for in sections 257 and 262 of the Supplemental Pension Plans Act (chapter R-15.1).