Triennial Return (for defined benefit plans only)

Name of employer or plan sponsor

Plan registration number

Reference date for valuation

• 1: YYYY MM DD

Uniform Statistical Program - Question identifier:A.

Going Concern Valuation Basis

Uniform Statistical Program - Question identifier:1.

Going concern liabilities with respect to: $ (Omit cents)

• 1: Active members
• 2: Deferred pensions
• 3: Pensions in pay (retired/beneficiaries)
• 4: Other
• 5: Total going concern liabilities

Uniform Statistical Program - Question identifier:2.

Going concern assets
$ (Omit cents)

Actuarial Assumptions Used for Valuation

Uniform Statistical Program - Question identifier:1.

Methods of valuing liabilities

• 1: Accrued benefit (unit benefit/credit)
• 2: Entry age normal
• 3: Attained age
• 4: Aggregate
• 5: Individual level
• 6: Other (specify)

Uniform Statistical Program - Question identifier:2.

Utilized value of assets

• 1: Book
• 2: Adjusted book
• 3: Market
• 4: Adjusted/average market
• 5: Average/blend of book and market
• 6: Other (specify)

Uniform Statistical Program - Question identifier:3.

Mortality tables

• 1: GAM 94
• 2: GAR 94
• 3: UP 94
• 4: GAM 83 (adjusted)
• 5: GAM 83
• 6: GA 71 (adjusted)
• 7: Other (specify)

Uniform Statistical Program - Question identifier:4.

Interest rate (If only one rate used, report on first line and put 99 in "years".)
_____% for the first ___ years
_____% after that

If above does not completely describe interest rates used, check here

Uniform Statistical Program - Question identifier:5.

Salary increase rate (If only one rate used, report on first
line and put 99 in "years".)
_._% for the first __ years
_._% after that

If above does not completely describe salary increase rates used, check here

Uniform Statistical Program - Question identifier:6.

Withdrawal rate used

• 1: Yes
• 2: No

Uniform Statistical Program - Question identifier:7.

Hours of work per plan year (Multi-Employer Pension Plans only)
_____hours of work

Uniform Statistical Program - Question identifier:8.

For plans providing automatic indexing of benefits based on the CPI
(If only one rate used, report on first line and put 99 in "years".)
Assumed growth rate in CPI:
_____% for the first ___ years
_____ % after that

If above does not completely describe assumed growth rates used, check here

Uniform Statistical Program - Question identifier:B.

Solvency Valuation Basis
Reference date for valuation Year/Month/Day

Uniform Statistical Program - Question identifier:1.

Solvency assets $ (Omit cents)

• 1: Market Value of Assets (Including adjustments for any
  receivables and payables but excluding any provision
  for wind-up expenses)
• 2: Amount of wind-up expense provision
• 3: Market Value of Assets net of expense provision

Uniform Statistical Program - Question identifier:2.

Solvency liabilities (market value basis, excluding any provision for
wind-up expenses)
$ (Omit cents)

Actuarial Assumptions Used for Valuation

Uniform Statistical Program - Question identifier:3.

Interest rate for calculating pension commuted values (active members)
(If only one rate used, report on first line and put 99 in "years".)
_____% for the first ___ years
____% after that

Uniform Statistical Program - Question identifier:4.

Indexation rate (if applicable) (If only one rate used, report on
first line and put 99 in "years".)
______% for the first ___ years
_____% after that

Uniform Statistical Program - Question identifier:5.

Mortality table

• 1: UP 94
• 2: Other (specify)

Completed by (please print):

Telephone no.:

Date:

Please return completed form to:
Pensions and Wealth Surveys Section
Income Statistics Division
Statistics Canada
Ottawa, Ontario K1A 0T6
Telephone : (613) 951-4031
Fax : (613) 951-4296

Thank you for your cooperation