First Name

Last Name

Cell Phone Number

Home Phone Number

The Best Time to Reach You is

Address: (Apt. No. - Street No. Street Name)

City

Province

Postal Code

E-Mail Address

Date of Birth (mm/dd/yyyy)

SIN Card Number

Marital Status

Your province or territory of residence on Dec. 31, 2004 is:

Ontario Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Terrotories Nova Scotia Nunavut Prince Edward Island Quebec Saskatchewan Yukon

The province or territory where you currently reside if it is not the same as that shown above for your address:

Ontario Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Prince Edward Island Quebec Saskatchewan Yukon

If you were self-employed in 2004, the province or territory of self-employment is:

Ontario Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Prince Edward Island Quebec Saskatchewan Yukon

If you became or ceased to be a resident of Canada in 2004, the date of entry is (mm/dd/yyyy):

the date of departure is (mm/dd/yyyy):

Spouse's First Name

Spouse's Last Name

Spouse's SIN Number

Spouse's Date of Birth (mm/dd/yyyy)

Spouse's Net Income

Was your spouse self-employed in 2004?

Do you have any children under 18? (if you check the "Yes" box, please fill in section 4.)

Yes No

Son/Daughter

Full Name

Date of Birth (mm/dd/yyyy)

Income

Daughter Son

Daughter Son

Daughter Son

Daughter Son

Business Income

Capital Gain

Support Payment Received

T3

T4

T4-AP

Childcare Expense

Interest on Student Loan

Property Tax Paid

Rent Paid

RRSP Contribution

Tuition Fee Paid

Support Payment

Donation

Capital Loss

Total Tax Paid

Medical Expense

Other