Form 169 - Statutory declaration for proof of eligible service (member)

Statutory declaration for proof of eligible service (member) -

former employment with an OMERS employer

SECTION 1 - MEMBER INFORMATION

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Any personal information provided on this form may be used to

update your membership profile.

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consent for its use and disclosure for the purposes set out in our

Privacy Statement, as amended from time to time. You can find out

more about our collection, use, disclosure and retention of personal

information by reviewing our Privacy Statement at www.omers.com.

Use this form to confirm eligible service in the OMERS Primary

Pension Plan, where, as a former employee, you have tried but are

unable to obtain proof of your service from your former OMERS

participating employer. The glossary on page 4 has definitions of

terms used in this form.

How to use this declaration form:

• Complete sections 1 to 5. If you need more space for previous

employment or service information, attach a separate sheet; include your

name and OMERS membership number.

• Attach supporting documents (see definition on page 4), for the periods of

employment in this declaration.

• Sign the completed declaration form (Section 5) in the presence of a

Commissioner of Oaths.

SECTION 2 - PREVIOUS EMPLOYMENT INFORMATION

Date of Birth (m/d/y)

First Name Middle Name Last Name

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OMERS Membership Number*

Employer Name

Apt/Unit Address City Postal Code

If you have more than one period of employment information to report, please attach a separate sheet; include your name and OMERS membership

number.

Yes, I was a full-time employee

*Your membership number appears on your Pension Report or any personalized statement from OMERS.

Name of Current Employer

Start Date (m/d/y) End Date (m/d/y)

Employment status during the period

Were you a full-time employee during the period? (See definitions of full-time and non-full-time employment on page 4.)

No, I was not a full-time employee

Enter the percentage of full-time hours worked. If your percentage worked varies over the period, enter an average percentage of

full-time hours spanning the entire period. For example, if you worked one year at 60% of full-time, and one year at 70% of full-time,

enter 65%.

Province

EmailHome Number Mobile Number

If yes, indicate the dates and the type of absence:

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F169 - Aug 2023

OMERS Membership Number

Yes

SECTION 3 - BREAKS IN SERVICE

Important! If you were not a full-time employee, OMERS must ensure that the amount of eligible service from Section 2 is not overstated. To the best of

your knowledge, please provide information on any breaks in service or absences during the employment period.

Were there any breaks in service, absences without pay, layoffs, or terminations during the period of employment in Section 2?

Start Date (m/d/y) End Date (m/d/y) Type of Absence

SECTION 4 - PREVIOUS PENSION PLAN INFORMATION

Were you a member of a registered pension plan (other than the Canada Pension Plan) during the service period above?

Yes No

If yes, please provide the following information:

Date you enrolled in the plan (m/d/y)Name of Registered Pension Plan Plan Registration Number

When you left your former employer, which option did you choose for the pension you earned? For example, deferred pension, or commuted value

transfer to an RRSP or LIRA?

Please read carefully before signing this declaration in the presence of a Commissioner of Oaths.

MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under oath

by virtue of the Canada Evidence Act. I understand that OMERS reserves the right to request that I provide additional information to prove my prior

service.

I confirm that I am not able to obtain proof of my employment service from my former employer for the period indicated in Section 2. I further understand

that should new information come to light that contradicts this Declaration, OMERS will remove the ineligible service from my OMERS record and the

following consequences may occur, including but not limited to:

• My early unreduced retirement date (without adjustment) shown on the OMERS pension report annually or shown previously in a pension estimate

may no longer be valid;

• The estimated early retirement pension amount shown previously on a pension estimate may no longer be valid;

• If I have concluded a buy-back that involves inaccurate information, the purchase contributions without interest that are not permissible in the OMERS

Plan will be returned as originally received (in cash or by RRSP transfer); I further understand there may be income tax implications if I have already

claimed these contributions as a deduction to my taxable income;

• If my pension has already commenced, I understand that I will be required to pay back the additional pension received, including inflation increases, as

a result of the ineligible service being included in my early retirement pension calculation.

_____________________________________________________________________ __________________________________

Member's Signature Date (m/d/y)

I, __________________________________________________ of _________________________________ in the Province of Ontario,

Name Name of City

SECTION 6 - TO BE COMPLETED BY A COMMISSIONER OF OATHS*

Declared before me at _________________________________ country of ________________________________ in the province or territory of

Name of City, Town or Village Country

_______________________________________________. Dated this ________ day of _________________________________, _______________.

Province or Territory Day Month Year

_____________________________________________________________ ________________________________________________________

Name of Commissioner of Oaths Signature of Commissioner of Oaths

Municipal Official: please provide the office you currently hold and the municipality:

_____________________________________________________________ ________________________________________________________

Office Municipality

Lawyer or judge: please provide your Law Society number:

Please affix seal/stamp here

________________________________________________________ if applicable

Law Society Number

*A Commissioner of Oaths can be:

• a lawyer entitled to practice law in Ontario;

• a judge or justice of the peace;

• a Notary Public;

• certain municipal officials (such as a City Clerk); or

• a person appointed as a Commissioner by the Attorney General.

OMERS Membership Number

SECTION 5 - MEMBER'S DECLARATION - to be signed in the presence of a Commissioner of Oaths

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Glossary

Breaks in service

A break in service could be any period of absence from an employer

without pay:

• where you did not contribute to the pension plan or subsequently

purchase the service in that plan; or

• your employer did not provide automatic pension coverage; or

• you did not have a PA reported.

Example: a period of pregnancy/parental leave, strike, or layoff (with or

without recall rights).

If a bona fide termination occurred (e.g., a contract or period of seasonal

work ended), this should be reported as the end date of a period

of employment.

Eligible service

Service with a participating OMERS employer that is not credited service

in the OMERS Plan. Eligible service may be purchasable in the OMERS

Plan. Eligible service can be used for the early retirement age+service

Factor (90 Factor or 85 Factor) or 30-years-of-service provision. More

about eligible service is in the OMERS Member Handbook, available at

www.omers.com.

Employment status

• Full-time

An employee hired as part of the permanent complement of the

employer, who works full-time hours (minimum 32 hours per week, for 52

weeks of the year including vacation) as specified by the employer, is

considered continuous full-time for OMERS purposes.

• Non-full-time

Any other arrangement (including an employee working full-time hours

on a time-limited contract basis) is not considered continuous full-time

for OMERS purposes. For these periods, provide the percentage of full-

time hours worked on average during the period.

Example: if full-time hours were 37.5 hours per week, and you regularly

worked 30 hours per week, the percentage of full-time hours worked

would be 80% (or 30 ÷ 37.5 = 0.80).

Pension adjustment (PA)

A pension adjustment (PA) is the value of the pension benefit a member

earned in the year in the employer’s registered pension plan. The PA is

reported annually to the Canada Revenue Agency (on the T4) and will

lower the amount of RRSP room available for a member for the

following year.

Registered pension plan (RPP)

A pension plan that has been registered with a pension regulator in a

Canadian jurisdiction (such as the Financial Services Regulatory

Authority of Ontario), and is also a registered plan under the Income Tax

Act (Canada) and Regulations.

Supporting documents

OMERS requires that you must submit supporting documents with the

statutory declaration demonstrating the periods of employment you are

declaring, as follows:

• A letter from your former employer (if they are still in existence)

confirming that they are unable to produce the service records. This

document must be accompanied by T4 slips, a summary of previous

tax returns, ROEs, or paystubs (clearly stating the name of the

employer and the member's name).

• T4 slip: a copy of your T4 income tax slip for each of the calendar

years of the employment period. Contact the Canada Revenue Agency

(CRA) to request a copy of your T4s.

• Record of employment: a copy of your Record of Employment (ROE)

for the employment period you are declaring. Contact Service Canada

to request a copy.

• Paystubs that apply to some or all of the period of time you are trying to

have recognized as eligible service.

T4 slip

The income tax form issued by your employer for reporting your taxable

income during a calendar year. A T4 will show taxable income, pension

adjustment (PA), a pension plan registration number, and any pension

contributions made.

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