Questionnaire

First Name: Last Name:

Address:

Telephone:

Date of birth:

Social Insurance Number:

Marital status as at 31 December:

In which province did you live

december 31?

Have you changed your address within the year?

Did you arrive in Canada or leave Canada during the year? If yes, specify the date.

Are you a Canadian citizen?

Is this the first time you have made a federal or provincial statement?

Would you like to receive your correspondence through my Revenue Canada file and through Revenu Québec's Clic Séqur?

Provide your email:

Did you have foreign investments that cost more than $100,000 during the year?

Did you sell a home during the year?

Did you buy a home for the first time during the year?

Have you lived alone or with a child under the age of 18 for the entire year?

Has your income increased significantly since last year?

Were you insured with your own insurance plan or that of your spouse/parent OR with the Quebec prescription drug insurance plan during the year?

Your insurer: Number of months:

RAMQ: Number of months:

Have you benefited from free medication through the guaranteed income supplement?

Do you have a spouse on December 31, that is, a person with whom you are married or a person with whom you have cohabited in a conjugal union for at least 12 months without interruption?

What is his net income for the year if we do not report him/her or other?

Did you have dependent children on December 31?

If so, what is their net income for the year if we do not report them?

Tell us any specific situations...