The Power Sector Retirement Trust

802-10 Carlson Court, Etobicoke ON M9W 6L2

Request for Withdrawal/Registered Investments Transfer Email to: info@psrt.ca or Fax to: 416-240-0993

Check one of the following to tell us what type of plan you’re withdrawing from:
Personal RRSP Spousal RRSP Tax Free Savings Account Non-Registered Savings Plan
Please print clearly.
1 Tell us about yourself
POWER SECTOR RETIREMENT PROGRAM – 36851 Telephone Number 613- 328- 6088
Your last name First name Initial Your Social Insurance Number

Dillon Kirk J 526 - 201 - 470

Your home address (number, street, apartment City or Town Province Postal Code
4258 Henderson rd Harrowsmith ON K0h 1v0
If you’re withdrawing from a spousal RRSP, please provide information about your spouse.
Your spouse’s last name First name Initial Your Spouse’s Social Insurance Number
- -
2 Withdrawals
Withdrawing from an RRSP
Check one of the following to tell us how much you want to withdraw
Please check one box:
Withdraw $ before tax (gross)
Withdraw all funds; contributions will continue after tax (net)
Withdraw the full Account value and end your membership
I understand that a Union Administrative Fee of $20.00 will be applied.

3 Payment method
Please check off one option only:
Make a cash withdrawal or Cheque or Direct Deposit (void cheque attached)
Transfer the withdrawal value, as indicated below, to another Registered Plan (Canada Revenue Agency Form T2033 with Parts I
and II or equivalent completed and attached).
HomeBuyers (RSP Plans only) - completed Canada Revenue Agency form T1036 completed and signed must be attached to this
form
LifeLong Learning (RSP Plans only) - Canada Revenue Agency form RC96 with Area 1 completed and signed must be attached to
this form.
. Purchase an annuity/RIF with London Life Insurance Company (with special arrangements).
Purchase an annuity/RRIF (Canada Revenue Agency Form T2033 with Parts I and II or equivalent completed and
attached).

4 Please sign here

By signing below, you acknowledge the following:
• we are required to withhold and report federal income tax, and if applicable Quebec income tax, on all withdrawals from a
registered plan where required.
• if you withdraw funds from a guaranteed investment before it matures, you will be subject to fair market value
• your withdrawal may be subject to a transaction fee.
• fax copy will be accepted.
You should sign here if this is not a spousal RRSP If this is a spousal RSP, both member and spouse must sign.
Member’s signature (in ink) Date (dd/mm/yyyy) Your spouse’s signature (in ink) Date (dd/mm/yyyy)
06/28/2021
5 To be completed by local union
CERTIFICATION THAT THE INFORMATION PROVIDED ABOVE IS CORRECT
Date (d/m/y) Plan Administrator Signature

Please return the completed form and any applicable government transfer forms to Power Sector.

Req for Withdrawal 36851 - 11/13 – 4-15