<NoName> SIN: Printed: 2020/03/29 13:22

Canada Revenue Agence du revenu Protected B

Agency du Canada when completed

Authorizing or Cancelling a Representative

You can view, add, modify, or cancel your authorized representatives online
using My Account at canada.ca/my-cra-account. Your representative will have
instant access to your information and online services to easily manage your
account. To immediately cancel a representative, call us at 1-800-959-8281.

Part 1 – Taxpayer account information

Complete the line that applies.
SIN, TTN or ITN First name Last name
___ ___ ___
513539924 edzevit azizoski

Trust account number Trust name

T

Part 2 – Representative information and authorization

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Complete section A or B, as applicable.
A. Authorize online access for all tax years (including access by telephone and in writing)

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Your representative must be registered with Represent a Client to obtain online access.
Rep ID
_______ First name: Last name:
Group ID
GPF6SB Group name: Canadian Benefits Association
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Business Number (BN)
_________ Business name:
Level of authorization (level 1 or 2): 2 Telephone: 647-492-8070
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B. Authorize access by telephone and in writing

First name: Last name:
Business name:
Telephone: ___-___-____ Ext: ______ Fax: ___-___-____
CA

Tick the appropriate box and indicate the level of authorization:

All tax years (past, present, and future) Level of authorization (level 1 or 2):
or
Specific tax year(s) with level of authorization (level 1 or level 2) indicated for each tax year.
Tax year(s)
Level of authorization

Part 3 – Authorization expiry date

Enter an expiry date, if applicable. Your representative's access to your information will stay Year Month Day
in effect until you or your representative cancel it, or we are notified of your death.

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<NoName> SIN: Printed: 2020/03/29 13:22
Protected B when completed

Part 4 – Cancel your representative

Complete this section to cancel your representative(s) and remove their access to your information. Tick the appropriate box.

Cancel all representatives.

or
Cancel the representative listed below:

Rep ID
_______ First name: Last name:
Group ID
G_____
Business Number (BN)
_________ Business name:

Part 5 – Signature and date

If you are the taxpayer, you must sign and date this form.
If you are the legal representative, you must tick the box below, sign and date this form.

I am the legal representative for this taxpayer or estate/trust

(executor, administrator, power of attorney, legal guardian or parent of a taxpayer under the age of 16, or trustee).

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Important: If you haven't already done so, you must send a complete copy of the legal document giving you the
authority to act in this capacity. If the taxpayer is under the age of 16, no legal document is required.
edzevit azizoski

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(___) ___-____
Name of taxpayer or legal representative Signee's telephone number
Year Month Day
X 06/27/2021
Signature of taxpayer or legal representative Date of signature
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The CRA must receive this form within 6 months of the date it was signed, or it will not be processed.
Personal information is collected under the Income Tax Act to administer tax, benefits, and related programs. It may also be used for any purpose
related to the enforcement of the Act such as audit, compliance and collection activities. It may be shared or verified with other federal, provincial,
territorial or foreign government institutions to the extent authorized by law. Failure to provide this information may result in interest payable,
NC

penalties or other actions. The social insurance number is collected under section 237 of the Act and is used for identification purposes. Under
the Privacy Act, individuals have the right to access, or request correction of, their personal information, or to file a complaint with the Privacy
Commissioner of Canada regarding the handling of their personal information. Refer to Personal Information Bank CRA PPU 005, CRA PPU 015,
CRA PPU 063, CRA PPU 140, CRA PPU 178 and CRA PPU 218 at canada.ca/cra-info-source.
CA

T1013 E (18) Page 2 of 3

 Canadian Benefit Association
A division of Herman & Meyer Accounting Services Inc.
www.CanadianBenefitAssociation.ca
40 Bradwick Drive Unit 1, Concord ON L4J 1K9
T: 1.844.336.1948 F: 647.847.5755

Client Fee and Business Pre‐Authorized Debit (PAD) Agreement

I confirm that Canadian Benefit Association a division of Herman and Meyer Accounting Services Inc. (“CBA”) has advised me that I, or certain individuals
related to me, may be eligible for certain disability‐related tax benefits from the Canadian and/or provincial governments. In addition, CBA is hereby retained
by the Client to pursue Federal and Provincial personal income and excise tax refunds and/or credits (collectively “Refunds”) that may be available with
respect to the Client tax filings during the previous 10 taxation years. In performing its obligations hereunder, CBA is and shall be deemed to be an
independent contractor and not a partner, agent or employee of Client. I hereby retain CBA to pursue these benefits, on the following terms:

CBA is authorized to act on my behalf in dealing with the Canada Revenue Agency (CRA), provincial agencies, health professionals, and such other parties
as may be appropriate in connection with the application process, and to obtain and disclose information about me from and to all such parties. I agree to
sign such consent forms as CBA deems advisable in connection with the application process (including, without limitation, Level 2 CRA authorization), and
to cooperate fully and promptly with CBA during and following the application process.

While CBA does not guarantee that any party will be entitled to any benefits, Canadian Benefit Association will be entitled to a fee equal to 33% (plus
GST/HST) of all benefits I, or any individuals related to me receive. Whether in the form of refunds or credits from the CRA or a provincial agency, or

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otherwise, in respect of the application prepared by CBA. I agree to notify CBA immediately upon the receipt of any such benefits by myself or any party
related to me. In the event that no such benefits are received, I will not be required to make any further payment to CBA. Canadian Benefit Association will
not be entitled to a fee in respect of any period following the time period that is the subject of the application prepared by CBA.

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Canadian Benefit Association‘s fee will be due five (5) business days from the receipt of any benefits by myself or any party related to me. Any fee, or
portion thereof, not paid when due will accrue interest at a rate of 2% per month (being 26.82% per year), and I will be responsible for CBA’s costs of
collecting its fees. Any returned cheques will be subject to a fee of $45.00.
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Client is solely responsible to provide CBA with valid and accurate information and documentation regarding any claim for Refund. Notwithstanding that
CBA may ask clarification questions regarding matters that arise during its review process, CBA will not otherwise audit or verify any information or
documentation submitted by Client. Client acknowledges and agrees that it is Client’s sole responsibility to provide CBA with complete, valid and accurate
information in order for CBA to claim the maximum Refund that may be available. Client must retain copies of all the receipts, cancelled checks and other
supporting documentation regarding any information provided to CBA. CBA will treat my information in accordance with the terms of its privacy policy and
NC

this agreement. I confirm that I have been provided with a current copy of CBA’s privacy policy, and acknowledge that CBA’s privacy policy may be revised
from time to time by CBA. At any time, the most recent version of CBA’s privacy policy will be available upon request.

I/we authorize Canadian Benefit Association, and the financial institution designated to effect deductions as per my/our instructions for CBA invoices
representing 33% plus applicable taxes for CRA refunds or credit received by me/us related to CBA’s tax review. A pre‐authorized debit for the full
amount of the services delivered will be debited from my/our specified account. A void cheque/direct deposit information will be provided to CBA. This
CA

authority is to remain in effect until CBA has received written notification from me/us of its change or termination. I/We may obtain a sample
cancellation form, or more information on my/our right to cancel a PAD Agreement at my/our financial institution or by visiting www.cdnpay.ca. I/we
hereby waive my/our right to receive pre‐notification of the amount of the PAD and agree that I/we do not require advance notice of the amount of the
PADs more than 3 days before the debit is processed. CBA may not assign this authorization, whether directly or indirectly, by operation of law, change
of control or otherwise, without providing at least 10 days prior written notice to me/us. I/we have certain recourse rights if any debit does not comply
with this agreement. For example, I/we have the right to receive reimbursement for any PAD that is not authorized or is not consistent with this PAD
Agreement. To obtain a form for a Reimbursement Claim, or for more information on my/our recourse rights, I/we may contact my/our financial
institution or visit www.cdnpay.ca

CBA will be entitled to make such determinations as it deems appropriate in connection with the application process, including, without limitation, whether
to amend, delay, or withdraw application.

Unless CBA has advised me in writing that it has terminated this agreement, I will remain responsible for CBA’s fee in the event that, independently of CBA,
I pursue an application for benefits in respect of all or part of the time period that was the subject of the application prepared by Canadian Benefit
Association. This agreement shall be governed by the laws of the Province of Ontario, and the courts of the City of Toronto in the Province of Ontario shall
have exclusive jurisdiction over any disputes relating to this agreement.

SIGN HERE:
Make sure you fill out all 3 boxes.

edzevit azizoski 06/27/2021

PRINTED NAME SIGNATURE DATE (MM/DD/YYYY)

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