For Office Use

Return form to Clubs & Volunteer Coordinator Date Received:

Community Volunteer Income Tax Program

INTAKE FORM

Legal Name: _______________________________ (like it is spelled on previous tax returns)

Social Insurance #____________________________ Date of Birth: ____________________________

Permanent Mailing Address:_____________________________________________________________

Phone # ___________________________________ Email Address: ____________________________

Are you a Canadian Citizen? (circle one) Yes / No

Did you live in Ontario on December 31st, 2021? (circle one) Yes / No

Did you enter Canada for school or work last year? Yes / No

If YES, date of entry into Canada: _________________________________________________

Marital Status (circle one): Single Common-Law Married Separated Divorced Widowed

IF you are eligible to receive the Trillium benefit, how would you like it paid out?
❑ Monthly installments ❑ Single payment in June 2022

2021 Rent Payments

# of
Landlord’s Name months Amount of rent Address
lived in paid per month
2021

OR
Property Tax Amount Paid in 2021: _______________________________________________________

Town/Municipality paid to: ______________________________________________________________

** PLEASE ATTACH ALL INCOME SLIPS & TAX RECIEPTS **

These may include:

❑ Income slips (T4, T5007, T4A etc.) ❑ Tuition Enrollment Certificate (T2202) ❑ RRSPs (T4RSP)

❑ Medical Receipts ❑ Charitable Receipts ❑ Childcare Receipts

❑ Grants/Scholarships (T4A)
For Office Use
Return form to Clubs & Volunteer Coordinator Date Received:

IF APPLICABLE:

SPOUSE/COMMON-LAW PARTNER INFORMATION

Did your marital status change in 2021? (circle one) Yes / No

If YES, date of change: ______________________ Spouse/Partner Citizenship: ______________________

Spouse or Partner’s Legal Name: _______________________________________________________________

Spouse or Partner’s Social Insurance #_____________________ Date of Birth:________________________

CHILDREN IN YOUR CUSTODY (Under 18 years old)

Child’s First & Last Name Date of Birth Child’s relationship to the taxpayer
(D/M/Y) (Son OR Daughter)

** ONLY ONE PARENT OR LEGAL GAURDIAN CAN CLAIM A CHILD FOR INCOME TAX PURPOSES **

******************************* Signature Required *******************************

DISCLAIMER

I am fully aware that my income tax and benefit return is being prepared by a volunteer under
the Community Volunteer Income Tax Program and that this volunteer is not acting as an agent
of the Canada Revenue Agency.

_________________________________ ____________________ _______________________________

Signature of Taxpayer Date Signed at (name of organizat