Tax Clinic Form 2017

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Tax Clinic
    TAX CLINICS APPLICATION Please bring the completed form to the 3d Floor Information Desk at the Central Library. The Library will contact you to book an appointment ONLY if you are eligible for free Tax Clinics. Please fill a separate form for each person applying. 1.   First name: _______________________________________________________________ 2.   Last name: _______________________________________________________________ 3.   Postal code: ______________________________________________________________ 4.   Phone number: ____________________________________________________________ 5.   Email address: _____________________________________________________________ 6.   When did you last file a tax return: ____________________________________________ 7.   What was your total (gross) income in 2016: ____________________________________   8.   Are you self-employed or do you have income from self-employment? ______________ 9.   Do you have rental and/or business income and expenses? ________________________ 10.   Are there other sources of income (such as investments, RRSPs, foreign income / property, etc.)? ____________________________________________________________ 11.   Are you filing for bankruptcy? ________________________________________________ 12.   Are you married? __________________________________________________________ If married, what was your spouse’s total income in 2016? _________________________ 13.   Do you have dependants? ___________________________________________________ If yes, how many? __________________________________________________________ How old are they? __________________________________________________________    14.   Is there anyone else in your household? If yes, do they receive income from other sources (e.g., parents or other extended family)? ________________________________ 15.   Were you a resident of Ontario on December 31, 2016? ___________________________ 16.   If you are a new immigrant, what was your date of entry into Canada? ______________ 17.   Did you sell your principal residence in 2016? ___________________________________ If yes, did you have capital gain? ______________________________________________ 18.   How did you hear about CPA Tax Clinics? -   Richmond Hill Library website ____________________________________________ -   Flyer__________________________________________________________________ -   Poster ________________________________________________________________ -   Word of Mouth_________________________________________________________ -   Case Worker___________________________________________________________ -   Social Media___________________________________________________________ -   Other_________________________________________________________________ ____________________________ (Signature) ____________________________ (Date)
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