Form RC376 "Taxpayer Relief Request - Statement of Income and Expenses and Assets and Liabilities for Individuals" - Canada

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Download Form RC376 "Taxpayer Relief Request - Statement of Income and Expenses and Assets and Liabilities for Individuals" - Canada

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Taxpayer Relief Request
Statement of Income and Expenses and Assets and Liabilities for Individuals
Information to help you complete this form
Use this form to provide full financial disclosure to support your taxpayer relief request to cancel interest or penalties based on your
inability to pay or financial hardship (see below for definitions and examples).
Complete this form and Form RC4288, Request for Taxpayer Relief. Send both forms together with all the supporting documentation
(see below for definitions and examples) to the appropriate intake centre as indicated on Form RC4288. You may submit photocopies
of supporting documentation.
If you are completing this form by hand, please print clearly. Attach an extra sheet if there is not enough space in any section of the form.
For more information about the taxpayer relief provisions, see Information Circular IC07-1, Taxpayer Relief Provisions or
GST/HST Memorandum 16-3, Cancellation or Waiver of Penalties and/or Interest, or go to the Canada Revenue Agency (CRA)
taxpayer relief Web pages at www.cra.gc.ca/taxpayerrelief.
Definitions and examples
Ability to pay: A taxpayer's current and future capacity to pay or borrow money, including the ability to borrow against significant assets or
liquidate significant non-essential assets to raise money for repayment, and avoiding repayment terms that will cause undue hardship.
Financial hardship: For an individual taxpayer, financial hardship refers to financial suffering or lack of what is needed for basic living
requirements, such as food, clothing, shelter, medical expenses, and reasonable non-essentials.
Household net income: The net income of the taxpayer and the taxpayer's spouse or common-law partner.
Supporting documentation: To support a request for relief based on an inability to pay or financial hardship, it is the taxpayer's responsibility
to provide relevant documentation that supports their financial situation. Documentation could include, but is not limited to, the following:
employment and/or other income statements or slips
mortgage statement
lease or rental agreement
property tax assessment and/or condo fees
loan statements
utility statements
bank statements (most recent three months)
investment statements
credit card statements
insurance (e.g., auto, home, life) statements
Note: You may submit photocopies of supporting documents.
Clear Data
Help
Taxpayer Relief Request
Statement of Income and Expenses and Assets and Liabilities for Individuals
Information to help you complete this form
Use this form to provide full financial disclosure to support your taxpayer relief request to cancel interest or penalties based on your
inability to pay or financial hardship (see below for definitions and examples).
Complete this form and Form RC4288, Request for Taxpayer Relief. Send both forms together with all the supporting documentation
(see below for definitions and examples) to the appropriate intake centre as indicated on Form RC4288. You may submit photocopies
of supporting documentation.
If you are completing this form by hand, please print clearly. Attach an extra sheet if there is not enough space in any section of the form.
For more information about the taxpayer relief provisions, see Information Circular IC07-1, Taxpayer Relief Provisions or
GST/HST Memorandum 16-3, Cancellation or Waiver of Penalties and/or Interest, or go to the Canada Revenue Agency (CRA)
taxpayer relief Web pages at www.cra.gc.ca/taxpayerrelief.
Definitions and examples
Ability to pay: A taxpayer's current and future capacity to pay or borrow money, including the ability to borrow against significant assets or
liquidate significant non-essential assets to raise money for repayment, and avoiding repayment terms that will cause undue hardship.
Financial hardship: For an individual taxpayer, financial hardship refers to financial suffering or lack of what is needed for basic living
requirements, such as food, clothing, shelter, medical expenses, and reasonable non-essentials.
Household net income: The net income of the taxpayer and the taxpayer's spouse or common-law partner.
Supporting documentation: To support a request for relief based on an inability to pay or financial hardship, it is the taxpayer's responsibility
to provide relevant documentation that supports their financial situation. Documentation could include, but is not limited to, the following:
employment and/or other income statements or slips
mortgage statement
lease or rental agreement
property tax assessment and/or condo fees
loan statements
utility statements
bank statements (most recent three months)
investment statements
credit card statements
insurance (e.g., auto, home, life) statements
Note: You may submit photocopies of supporting documents.
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Taxpayer Relief Request
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Statement of Income and Expenses and Assets
and Liabilities for Individuals
Please read "Information to help you complete this form" on the first page above. Complete all sections of this form. Please print
clearly if you are completing this form by hand.
Name:
Date:
Home address:
Social Insurance Number (SIN):
Daytime telephone:
Evening telephone:
Employer name and address:
Self-employed: attach current business financial statements and a copy of Form T2125 – Statement of
Business numbers (BN):
Business or Professional Activities
Spouse's/common-law partner's name:
Spouse's/common-law partner's SIN:
Number of dependants:
Age of dependants:
Monthly Household Net Income and Expense Statement
Household net income
Monthly
Expenses
Monthly
Employment income
Housing: Mortgage / rent
Commissions / bonuses
Property taxes / condo fees
Old Age Security pension (OAS )
Repairs / maintenance
CPP / QPP benefits
Insurance
Disability benefit
Utilities: Telephone, including cellular
Pension (employment, RRSP, RRIF, etc.)
TV / Internet
Universal child care benefit (UCCB)
Electric / water
Canada child tax benefit (CCTB)
Heating
Employment insurance benefits
Groceries
Investment income (dividends, interest, TFSA)
Child care
Rental income (include room and board)
Vehicles: Loan / lease payment
Spousal / child support
Loan / lease payment
GST / HST credit
Insurance (all vehicles)
Scholarships / bursaries
Gas / oil (all vehicles)
Business / professional income
Maintenance (all vehicles)
Farming / fishing income
Spousal / child support payments
Workers' compensation benefits
Public transportation / parking
Working income tax benefit (WITB)
Medical premiums (Blue Cross, Sun Life, etc.)
Social assistance payments
Medical expenses (prescriptions, dental, etc.)
Other income (specify)
Clothing / personal care
Spouse's / common law partner's net income
Education (adults and dependants)
*Other contributions to household income
Membership / club fees
Total Income: $
Recreation / entertainment / dining out
Tobacco / alcohol
Credit card payments
*When the CRA determines an individual's ability to pay, it may be necessary to
take into consideration the income and expenses of the family unit. All factors
Bank loans (other than vehicles listed above)
affecting an individual's financial situation are reviewed to determine the ability
Other loans / payments (business, relatives, etc.)
to pay.
Donations
Investments (RRSP, RESP, TFSA, etc.)
Life insurance premiums
Other expenses (specify)
Total expenses: $
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Asset Statement
Bank accounts
Bank (name and address)
Balance
1.
2.
3.
Real estate
Address
Owner(s)
Market value
Primary residence
Rental / investment properties
Recreation (cottage, etc.)
Land / other
Investments / Savings (name of holder) (attach a separate page if necessary)
Market value
RSP / RRSP / RRIF / TFSA
Bonds
Maturity date:
GIC's
Maturity date:
Stocks
Publicly traded?:
Yes
No
Other
Details:
Are you a director, shareholder or partner of any other business?
Details:
Yes
No
All vehicles (make / model / year)
Market value
1.
2.
3.
4.
Other assets (collectibles, antiques, vehicles not listed above, etc.)
Market value
Total assets: $
Liability Statement
Bank loans and name of bank
Term, completion date, and security held
Balance owing
1.
2.
3.
Other loans / Creditors (business, relatives, etc.)
Balance owing
1.
2.
Mortgage holder(s)
Balance owing
1.
2.
Guaranteed debts (co-signed)
Balance owing
1.
2.
Vehicle leases
Balance owing
1.
2.
Credit cards and name of issuer
Balance owing
1.
2.
3.
Other Debts
Completion date
Balance owing
1.
2.
Total liabilities: $
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