HMC Income Tax Clinic Intake Form CLIENT INFORMATIONPlease read carefully the eligibility criteria below:ELIGIBILITY CRITERIA FOR THE INCOME TAX CLINIC Income limits: •Single person with combine income from all sources below $35,000 •Couple with combined income from all sources below $45,000 •Couple with child with combined income from all sources below $47,500 •For each additional dependent, add $2,500 to the income threshold •Earned interest income below $1,000 You must also have: •No self-employment income •No foreign income •No foreign property By filling out this form, you confirm that you meet the eligibility criteria above. If you submit this form but do not meet the eligibility criteria, our volunteers will not be able to submit your Income Tax Return.Intake FormAre you an HMC client?(Required) Yes NoName(Required) First Last Date of Birth(Required) YYYY slash MM slash DD Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon 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, OakvilleLanguage(Required)Preferred language for Income Tax Preparation English French Arabic Mandarin Ukrainian Hindi Punjabi Urdu Tagalog/Filipino Korean OtherCurrent Marital Status(Required) Single Separated Divorced Widowed Married Common-LawName of spouse or common-law partner:Children, if any:First & Last NameDate of Birth (YYYY/MM/DD) Add RemoveAre you experiencing homelessness?(Required) Yes NoHow did you find out about this Income Tax Clinic?(Required)Rent Paid or Property TaxTotal rent you paid in 2023 (CND):Total property taxes you paid in 2023 (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 NoIMMIGRATION STATUSStatus(Required)Canadian CitizenPermanent ResidentConvention RefugeeRefugee ClaimantStudy PermitWork Permit - CUAETWork PermitDate of Arrival in Canada YYYY slash MM slash DD Are you an international student?(Required) Yes NoDid your marital status change during this filing year?(Required) Yes NoWhen? (date) YYYY slash MM slash DD Do you own any foreign property worth $100,000 or more?(Required) Yes NoAre you self-employed?(Required) Yes NoAre you a senior?(Required) Yes NoDid you sell your primary residence last year? Yes NoINCOMETotal income earned in Canada for year 2023 (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 InvestmentDid you receive: CRB CRCB CRSB CWLBIf you made a government repayment, what was the amount?Foreign Pension? (World Income in CDN Dollars)Country of Origin:DEDUCTIONSDeductions 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 planEligible employees who worked from home in 2023 will be required to use the detailed method to claim home office expenses. The temporary flat rate method does not apply to the 2023 tax year.Other Deductions:If eligible for the Ontario Trillium Benefit, I would like to receive the benefit: Monthly Lump Sum payment next JuneCONSENTDisclaimer(Required)Check the checkbox if you agree with the following disclaimer. ConsentCommunity Volunteer Income Tax Program Taxpayer DisclaimerThe 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.SIGNATUREDate(Required) YYYY slash MM slash DD Signatures(Required)By typing my name below, I confirm that I have read and understood the information above.