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 spouses 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)

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(Date)