This questionnaire is designed to assist you in compiling the information necessary to prepare your 2011 personal tax return. Please return this form with your documentation.

Client Name:___________________________________

Telephone (      )                            Fax (      )                          E-mail____________________

Please indicate address only if changed since 2009 income tax return

Marital status (if changed in 2011, indicate change and date)

r For wholly-dependent persons, please attach list and indicate for each dependant: name, address if different, relationship, birth date, S.I.N., and net income. Note infirmity, if any.

Please check items that you have attached:

INCOME

r  Employment - T4

r  Old Age Security - T4A(OAS)

r  Canada Pension Plan benefits - T4A(P)

r  Other Pensions - T4A

r  Employment Insurance - T4E

r  Universal Child Care Benefits - RC62

r  Interest, Dividends and other Investment Income T5/T600

r  Mutual Funds and other Trust Income - T3

r  Limited Partnership - T5013

r  Business or Professional - Financial Statements or T5013

r  Rental Property (attach details of income, expenses, purchases and sales)

r  Capital Gains/Losses (attached realized gain/loss report -ask your broker if you have not received one)

r  Did you dispose of any capital properties this year? (Attach copies of sales detail and original purchase documentation.)

r  Alimony (provide copy of post-April 30, 1997 agreement or election, if changed or not previously provided)

r  Other Income (e.g., stock options, annuities, scholarships, bursaries, research grants, RRSPs -attach T4RSP, Workers’ Compensation benefits).

DEDUCTIONS

r  Registered Retirement Savings Plan contributions (attach receipts)

      (Attach T10 - Personal Adjustment Reversal, if you received one.)

r  Annual union, professional dues (attach receipts)

r  Child care expense (attach receipts)

(a) for individual providers, include S.I.N. and address

(b) for summer camps, indicate number of weeks that were in-residence

(c) Child artistic learning costs outside of school -NEW

r  Attendant care expenses (attach receipts)

r  Allowable business investment losses (refer to Capital Gains/Losses above)

r  Moving expenses (attach receipts). Indicate distance moved to new employment

r  Alimony or separation allowances paid (include name(s) and address(es) of recipients; attach copy of agreement or court order for spousal support which was signed on or after May 1, 1997 or election, if changed or not previously provided)

r  Commission and employment expenses (include details and T2200 or TL2)

r  Carrying charges (interest on money borrowed to earn dividend and interest, investment counsel fees, interest for limited partnerships, safety deposit box)

r  Other deductions and expenses (attach receipts)

r  Federal and provincial political contributions (attach receipts)

r  Charitable donations (attach receipts)

(Provide details of donations of securities)

r  Medical expenses (attach receipts) and details of private health insurance premiums, including

amounts paid while travelling (for dependants over age 18, up to $10,000 can be transferred).  To avoid duplication of claims and the retrieval of multiple receipts, you may wish to obtain an annual summary from your service provider

r  Disability deduction for you or dependant (if first time claim, attach T2201 signed by physician)

r  Adoption expenses

r  Monthy TTC/GO or other public transit expenses

r  Tuition fees (attach signed T2202/T2202A including amounts that can be transferred from dependants)

r  Details of monthly public transit passes for the year (include passes for your spouse and children under 19 at the end of the year)

r  Interest paid on student loans (attach reporting slip)

r  Children’s fitness receipts for the year

OTHER

†  2011 Installments . Total remitted: $

†  Attach copy of 2010 assessment notices

†  Amount of any distributions or loans from foreign trusts received in 2011

†  Details of foreign property, other than personal use property, if aggregate cost is in excess of $100,000.

COMMENTS

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