Form T100A "Flow-Through Share Information - Application for a Selling Instrument T100 Identification Number (Sitin)" - Canada

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T100A
FLOW-THROUGH SHARE INFORMATION
APPLICATION FOR A SELLING INSTRUMENT T100 IDENTIFICATION NUMBER (SITIN)
If you need the instructions, search for publication T100, Instructions for the Flow-through Share Program on
Do not use this area
our website at www.canada.ca.
To request a SITIN, complete this form and file it with the selling instrument and/or agreement.
A corporation filing Form T100A should send it directly to: Canada Revenue Agency, Business
Returns Division, Prince-Edward Island Tax Center,
275 Pope Road, Summerside PE C1N 5Z7.
SL rev. type 0051, acc type 308
On this form, legislative references are to the Income Tax Act, and regulatory references are to the
Income Tax Act Regulations.
The assignment of the SITIN is for identification purposes only. The SITIN does not imply that the shares are flow-through shares, that the agreement or the
expenses meet all or any of the requirements of the Income Tax Act with respect to flow-through shares, or that we accept the allocation of the price
between the shares and the warrants. The corporation may be subject to an audit.
Complete Application Checklist
Filing a complete application will speed up its processing. Before sending your application, check if you have:
1. Used the current version of Form T100A for the application. Signed and dated Form T100A in the "CERTIFICATION" area.
2. Filled out the most current Program Identifier, i.e. RC000#, in part 1.
3. If a penalty applies, enclosed a cheque payable to the Receiver General for the full amount of the penalty.
4. Attached the selling instrument. If there are only subscription agreements, then the earliest signed agreement should accompany this form.
5. Recorded all of the pertinent information from the selling instrument or subscription agreement on the form and answered all questions.
6. Attached Form T100B, Details of the Flow-Through Shares (FTSs) and Flow-Through Warrants (FTWs) Subscribed for the sales to date.
Private
Public
Part 1 – General Information (please print)
Type of corporation
Name of corporation
Corporation account number
R C
Corporation address
Mailing address (if different)
City
Province
City
Province
Postal code
Postal code
same as corporation
Location of records (if different)
Contact person and title
same as mailing
City
Province
Postal code
Telephone number
Fax number
Part 2 – Exploration and Development Sector Information
A. Oil and Gas Sector
B. Mining Sector
Oil and Gas Extraction*:
Identify the principal mineral or combination of minerals that you expect the
exploration activity to be focused on:
Conventional oil and gas extraction
Non-Metallic Minerals
Metal Ores
Non-conventional oil and gas extraction
Iron
Nickel - Copper
Diamond
Halite
(*)
Conventional oil and gas extraction relates to petroleum
and natural gas from wells using normal pumping
Gold
Copper-Zinc
Gypsum
Kaolin
techniques. Non-conventional oil extraction relates to
surface shales or tar sands or from reservoirs in which
Other
the hydrocarbons are semisolids and conventional
Silver
Uranium
Sylvite
Non-Metallic
production methods are not possible.
Ammonite
Lead-Zinc
All other matals
Sillica**
Gemstone
C. Renewable and Conservation of Energy Sector
Calcium
Certified by
Coals
Select the type of energy source that best describes the
Chloride
the
Minister***
activity that you will be engaged in:
Bittimunous
Subbituminous
Cogeneration
Wind
Lignite
(**) The principal mineral is silica extracted from sandstone or quartzite.
Small hydro
Photovoltaics
(***) A mineral deposit that the Minister or Natural Resources has certified that the
principal mineral extracted is an industrial mineral contained in a non-bedded deposit.
Other (specify)
Industrial minerals are non-metallic, non-fuel minerals used in the chemical and
manufacturing industries. Attach a copy of the certificate that the Minister issued.
T100A E (18)
(Ce formulaire existe en français.)
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T100A
FLOW-THROUGH SHARE INFORMATION
APPLICATION FOR A SELLING INSTRUMENT T100 IDENTIFICATION NUMBER (SITIN)
If you need the instructions, search for publication T100, Instructions for the Flow-through Share Program on
Do not use this area
our website at www.canada.ca.
To request a SITIN, complete this form and file it with the selling instrument and/or agreement.
A corporation filing Form T100A should send it directly to: Canada Revenue Agency, Business
Returns Division, Prince-Edward Island Tax Center,
275 Pope Road, Summerside PE C1N 5Z7.
SL rev. type 0051, acc type 308
On this form, legislative references are to the Income Tax Act, and regulatory references are to the
Income Tax Act Regulations.
The assignment of the SITIN is for identification purposes only. The SITIN does not imply that the shares are flow-through shares, that the agreement or the
expenses meet all or any of the requirements of the Income Tax Act with respect to flow-through shares, or that we accept the allocation of the price
between the shares and the warrants. The corporation may be subject to an audit.
Complete Application Checklist
Filing a complete application will speed up its processing. Before sending your application, check if you have:
1. Used the current version of Form T100A for the application. Signed and dated Form T100A in the "CERTIFICATION" area.
2. Filled out the most current Program Identifier, i.e. RC000#, in part 1.
3. If a penalty applies, enclosed a cheque payable to the Receiver General for the full amount of the penalty.
4. Attached the selling instrument. If there are only subscription agreements, then the earliest signed agreement should accompany this form.
5. Recorded all of the pertinent information from the selling instrument or subscription agreement on the form and answered all questions.
6. Attached Form T100B, Details of the Flow-Through Shares (FTSs) and Flow-Through Warrants (FTWs) Subscribed for the sales to date.
Private
Public
Part 1 – General Information (please print)
Type of corporation
Name of corporation
Corporation account number
R C
Corporation address
Mailing address (if different)
City
Province
City
Province
Postal code
Postal code
same as corporation
Location of records (if different)
Contact person and title
same as mailing
City
Province
Postal code
Telephone number
Fax number
Part 2 – Exploration and Development Sector Information
A. Oil and Gas Sector
B. Mining Sector
Oil and Gas Extraction*:
Identify the principal mineral or combination of minerals that you expect the
exploration activity to be focused on:
Conventional oil and gas extraction
Non-Metallic Minerals
Metal Ores
Non-conventional oil and gas extraction
Iron
Nickel - Copper
Diamond
Halite
(*)
Conventional oil and gas extraction relates to petroleum
and natural gas from wells using normal pumping
Gold
Copper-Zinc
Gypsum
Kaolin
techniques. Non-conventional oil extraction relates to
surface shales or tar sands or from reservoirs in which
Other
the hydrocarbons are semisolids and conventional
Silver
Uranium
Sylvite
Non-Metallic
production methods are not possible.
Ammonite
Lead-Zinc
All other matals
Sillica**
Gemstone
C. Renewable and Conservation of Energy Sector
Calcium
Certified by
Coals
Select the type of energy source that best describes the
Chloride
the
Minister***
activity that you will be engaged in:
Bittimunous
Subbituminous
Cogeneration
Wind
Lignite
(**) The principal mineral is silica extracted from sandstone or quartzite.
Small hydro
Photovoltaics
(***) A mineral deposit that the Minister or Natural Resources has certified that the
principal mineral extracted is an industrial mineral contained in a non-bedded deposit.
Other (specify)
Industrial minerals are non-metallic, non-fuel minerals used in the chemical and
manufacturing industries. Attach a copy of the certificate that the Minister issued.
T100A E (18)
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Part 3 – Selling Instrument and Subscription Agreement Information
Step 1 – Selling Instrument and Subscription Agreement
Do you expect the subscription agreements to be signed in the same calendar year?
Yes
No
(An identification number will be assigned to the group of agreements signed in each calendar year)
Was a selling instrument (prospectus, offering memorandum, term sheet, etc.) issued to promote the offering?
Yes
No
Enter the earlier date of the first agreement signed or of a selling instrument that was first delivered to a potential
investor?
YYYY-MM-DD
Form T100A must be completed and filed on or before the last day of the month following the earlier of:
The month in which the corporation entered into the agreement to issue the shares; and
The month in which the corporation first delivered the selling instrument to a potential investor.
If the deadline has passed, please complete Part 4 – Penalty Calculation below.
Step 2 – Subscription proceeds
Flow-through shares (FTSs)
Maximum number of FTSs that will be issued if the entire offering is sold, or if no selling instrument is
used, the total number of FTSs that is expected to be issued
(10)
Price per FTS (*)
(11) $
×
(12) $
Maximum total proceeds from the issuance of FTSs
(10)
(11)
(*) Share price must be determined no later than 60 days from the date the agreement is entered into as set out in paragraph 6202.1(2)(a) of
the Income Tax Regulations.
Flow-through warrants (FTWs) (**) (only if that portion of the proceeds is to be spent on eligible resource expenditures)
Maximum number of FTWs that will be issued if the entire offering is sold, or if no selling instrument is
(15)
used, the total number of FTW that is expected to be issued
(16) $
Price per FTW
×
Maximum total proceeds from the issuance of FTWs
(15)
(16)
(17) $
+
Total subscription proceeds to be spent on eligible resource expenditures (12)
(17)
(18) $
(**) Includes a right to have a FTS issued.
Form T100B should be filed as soon as the total amount raised is known.
Step 3 – Flow-through warrants (FTWs) to be exercised in the future
Will the shares issued upon exercise of the warrants be FTSs?
Yes
No
If no, skip this step.
Maximum number of FTWs that will be issued if entire issue is sold, or if no selling
instrument is used, estimate of total FTWs to be issued
(20)
(21)
Exercise price per FTW
×
(22)
Maximum total proceeds from the future exercise of the FTWs
(20)
(21)
Expiry date of the FTWs
If the FTWs can be exercised subsequently at another price,
YYYY-MM-DD
and the expiry date
please provide that other price per FTW $
Form T100C, Flow-Through Share Information
Application for a T100 Identification Number (TIN) on the Exercise of Flow-Through Warrants
(FTWs) and Details of the FTWs Exercised should be completed and filed as soon as the actual number of FTWs exercised is known.
Part 4 – Penalty Calculation
Calculation of the penalty under subsections 66(12.74) and 66(12.75) for late filing of this form
(A)
Minimum penalty
$ 100
×
Amount on line (18)
(B)
1/4 of 1%
(C)
Maximum penalty
$ 15,000
(28)
Penalty: the median value of (A), (B), and (C) or if two of the amounts are equal, that value
Payment enclosed (cheques should be made payable to the Receiver General)
CERTIFICATION
I certify that the information given on this form is to the best of my knowledge, true, correct, and complete.
Date
Name of Authorized Officer (Print)
Position or Title (Print)
Signature of Authorized Officer
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