DECLARATION OF THE PURCHASER
(1) that I was at least 54 years of age but less than 65 years of age at the end of last year;
(2) that the total amount of the temporary pensions and variable benefits that I will receive during the current year under the following plans or contracts:
(a) supplemental pension plans subject to or established by an act of the Parliament of Québec or any other legislative authority;
(b) annuity purchase contracts of which the capital comes directly or not from such plans,
(3) that the overall total maximum temporary income that I have determined for my life income funds, excluding the one for which I am making this declaration, is $_______________;
(4) that the overall total maximum temporary variable payments that I have determined for the locked-in accounts of my voluntary retirement savings plans governed by the Voluntary Retirement Savings Plans Act (chapter R-17.0.1), excluding the one for which I am making this declaration, is $__________.
NOTE: Whosoever makes a false declaration with the intention of obtaining a temporary income payable under a pension plan or contract 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).