Form No 7: Annual Administrative Fees "*" indicates required fields Due Date* DD slash MM slash YYYY (No later than 30 June of each applicable calendar year)Plan Reporting Year End* (All sections must be completed, as applicable)1: Registration/Reference number 2: Name of Pension Plan/Local Retirement Product 3: Plan AdministratorCompany Name Contact Email Telephone (Area code) 4: Administrative Fee Calculation (at plan’s or local retirement product’s year-end)Financial Institution Pension Plan Quantity Price: $30.00 Quantity Provide Number of Members/Former MembersLocal Retirement Product Quantity Price: $30.00 Quantity Provide Number of Members/Former MembersIndividual Plan self-administered by an employer Quantity Price: $30.00 Quantity Provide Number of Members/Former MembersMulti-Employer Plan (Hotel Pension Fund & Restaurant Pension Plan) Quantity Price: $30.00 Quantity Provide Number of Members/Former MembersIndividual Plan administered by a third party administrator Quantity Price: $30.00 Quantity Provide Number of Members/Former MembersTotal Payable Pay/Paid by* Wire Transfer/Cheque Credit/Debit Card Credit/Debit Card Information* MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name Upload proof of payment (if cheque or wire transfer)Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 20 MB.5: CertificationAs the authorized officer of the administrator of the above noted pension plan or local retirement product, I certify that all the information presented on this form is true to the best of my knowledge and belief.DATED* DD dash MM dash YYYY Signature of Witness Reset signature Signature locked. Reset to sign again Signature of authorized signing officer Reset signature Signature locked. Reset to sign again Name of Witness (please print) Name of authorized signing officer (please print) Address of Witness Title/Position (please print)
