HMC Income Tax Clinic Intake Form

CLIENT INFORMATION

Are you an HMC client?(Required)

Yes

Name(Required)

First Last

Date of Birth(Required)

YYYY slash MM slash DD

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

How would you like to book your appointment

Online via Microsoft Office Teams

In person - at HMC office, Burlington

In person - at HMC office, Milton

In person - at HMC office, Dundas, Oakville

In person - at HMC office, Speers, Oakville

Language(Required)

Preferred language for Income Tax Preparation

English

French

Arabic

Mandarin

Ukrainian

Hindi

Punjabi

Urdu

Tagalog/Filipino

Korean

Other

Current Marital Status(Required)

Single

Separated

Divorced

Widowed

Married

Common-Law

Name of spouse or common-law partner:

Children, if any:

First & Last Name

Date of Birth (YYYY/MM/DD)

Are you experiencing homelessness?(Required)

Yes

How did you find out about this Income Tax Clinic?(Required)

Rent Paid or Property Tax

Total rent you paid in 2022 (CND):

Total property taxes you paid in 2022 (CND):

If you paid property tax and were 64 or older on Dec. 31 of the previous year you could be eligible for the Ontario Seniors Homeowners’ Property Tax Grant. Would you like to apply?

Yes

IMMIGRATION STATUS

Status(Required)

Date of Arrival in Canada

YYYY slash MM slash DD

Are you an international student?(Required)

Yes

Did your marital status change during this filing year?(Required)

Yes

When? (date)

YYYY slash MM slash DD

Do you own any foreign property worth $100,000 or more?(Required)

Yes

Are you self-employed?(Required)

Yes

Are you a senior?(Required)

Yes

Did you sell your primary residence last year?

Yes

INCOME

Total income earned in Canada for year 2022 (CND):(Required)

Income (check all that apply)

Employment T4

Pension T4A

T4E, EI, CERB & Other Benefits

T4RIF/T4RSP RRSP Income

Old Age Security T4OAS

ODSP/OW/Social Assistance T5007

Investment T5/T3

CPP T4AP

WSIB

T5/T3/T5008 Investment

Did you receive:

CRB

CRCB

CRSB

CWLB

If you made a government repayment, what was the amount?

Foreign Pension? (World Income in CDN Dollars)

Country of Origin:

DEDUCTIONS

Deductions

Medical

RRSP

Donations

Tuition, Textbooks Amount

Interest Paid on Student Loan

Disability Amount

Childcare

Moving Expenses

Canada Training Credit

Caregiver Amount

CPP and other Pension adjustments

Union/Professional Fees

Other (Tax credit on jobs training, Senior Tax Credits, LIFT, Ontario Staycation, etc.)

Dental not covered by health plan

Home Office Claim: Employees who worked more than 50% of the time from home, for at least four consecutive weeks in 2022 due to the COVID-19 pandemic, can claim $2 for each day worked from home to a maximum of $500 per individual. Vacation/sick days cannot be claimed. Number of Days you want to claim:

Other Deductions:

If eligible for the Ontario Trillium Benefit, I would like to receive the benefit:

Monthly

Lump Sum payment next June

CONSENT

Disclaimer(Required)

Check the checkbox if you agree with the following disclaimer.

Consent

Community Volunteer Income Tax Program Taxpayer Disclaimer

The Community Volunteer Income Tax Program (CVITP) is a collaboration between the Canada Revenue Agency (CRA) and Halton Multicultural Council Connections. HMC will host an online tax preparation clinic and arrange for volunteers to prepare income tax and benefit returns for eligible individuals, who are unable to prepare their returns.

CVITP volunteer would only provide assistance with the completion of my personal income tax return forms, based on the information I provide. Volunteers will prepare and file basic income tax returns for eligible tax payers in accordance with CRA guidelines, using the Community Volunteer Income Tax Program tax software provided.
CVITP Volunteers and HMC do not retain any records with respect to my income tax file. I authorize the CVITP to access my personal information through the Canada Revenue Agency on my behalf. However, volunteers and HMC cannot assist me with any matters concerning my Income Tax Return.
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. The tax return will be e-filed and the tax summary will be e-mailed.
I declare that the information provided the income reported are correct and complete, and fully discloses my income from all sources.
CVITP and Halton Multicultural Council are not liable for any errors/omissions or missing information.
If my income tax return requires changes after it has been submitted or if I have any questions about my income tax return, such as the status of my Notice of Assessment, I will contact Canada Revenue Agency general Enquiries directly at 1-800-959-8281.
This information is not intended or written to be used, and cannot be used or relied upon, by any individual for the purpose of avoiding legal obligations or tax penalties. Individual should seek advice based on the individual’s particular circumstances from an independent tax or legal advisor, should they choose too. In addition, HMC Connections disclaims any responsibility or liability related to client’s providing their information to any third party organizations or persons.

SIGNATURE

Date(Required)

YYYY slash MM slash DD

Signatures(Required)

By typing my name below, I confirm that I have read and understood the information above.