Canada Revenue Agence du revenu Protected B when completed

Agency du Canada

Income Tax and Benefit Return 2019

Before you start:

If you are filling out this return for a deceased person, make sure you enter their information in all the boxes in Step 1.

Step 1 – Identification and other information ON 7

Identification Information about you
First name richard Your social insurance number (SIN): 604 681 684
Last name moszynski Your date of birth (yyyy/mm/dd): 1946/09/28
Mailing Address: Your language of correspondence: English Français
Care of Votre langue de correspondance : X
Apt. No.
No./Street 98B Boucher Rd Is this return for a deceased person?
PO Box, RR 216-55 RR2 Ensure the SIN information above is for the deceased person.
City Fort Frances If this return is for a deceased
Prov./Terr. ON Postal code P9A3M3 person, enter the date of death (dd/mm/yyyy):

Marital status
Email address

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By providing an email address, you are registering to receive Marital status on December 31, 2019: 1. Married
email notifications from the CRA and agree to the Terms of use

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under Step 1 in the guide. Information about your spouse or
Enter an email address: common-law partner (if applicable)

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Information about your residence
A Enter their SIN: 616 165 684
Enter your province or territory of residence

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N C
on December 31, 2019: Ontario Enter their first name: Helen
B
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Enter the province or territory where you currently reside Enter their net income for 2019
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if it is not the same as your mailing address above: to claim certain credits: 35,994 73
Enter the amount of universal child
If you were self-employed in 2019, enter the province or territory care benefit (UCCB) from line 11700
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where your business had a permanent establishment: of their return:

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Enter the amount of UCCB repayment

from line 21300 of their return:
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If you became or ceased to be a resident of Canada for income tax

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purposes in 2019, enter the date of: Tick this box if they were self-employed in 2019: 1
entry (mm/dd) or departure (mm/dd)
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Do not use this area

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Do not use
this area 17200 17100
5006-R Page 1
Name: richard moszynski SIN: 604 681 684
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Step 1 – Identification and other information (continued)

Please answer the following questions.

Elections Canada (For more information, see "Elections Canada" under Step 1, in the guide.)
A) Do you have Canadian citizenship? Yes X 1 No 2
If yes, go to question B. If no, skip question B.
B) As a Canadian citizen, do you authorize the Canada Revenue Agency to give your name, address,
date of birth, and citizenship to Elections Canada to update the National Register of Electors or, if
you are aged 14 to 17, to update the Register of Future Electors? Yes X 1 No 2

Your authorization is valid until you file your next tax return. Your information will only be used for purposes permitted under
the Canada Elections Act, which include sharing lists of electors produced from the National Register of Electors with
provincial and territorial electoral agencies, members of Parliament, registered and eligible political parties, and candidates
at election time.

Your information in the Register of Future Electors will be included in the National Register of Electors once you turn 18.
Information from the Register of Future Electors can be shared only with provincial and territorial electoral agencies that are
allowed to collect future elector information. In addition, Elections Canada can use information in the Register of Future

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Electors to provide youth with educational information about the electoral process.

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Indian Act – Exempt income
Tick this box if you have any income that is exempt under the Indian Act.
A
For more information on this type of income, go to canada.ca/taxes-aboriginal-peoples.
Y 1
N C
B
If you tick the box, get and complete Form T90, Income Exempt under the Indian Act. Complete this form so that the CRA
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can calculate your Canada training credit limit for the 2020 tax year. The information you provide may also be used to
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calculate your Canada workers benefit for the 2019 tax year, if applicable.
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Foreign property
Did you own or hold specified foreign property where the total cost amount of all such
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property, at any time in 2019, was more than CAN$100,000? 26600 Yes 1 No X 2
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If yes, get and complete Form T1135, Foreign Income Verification Statement. There are substantial penalties for not
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completing and filing Form T1135 by the due date. For more information, see Form T1135.
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Name: richard moszynski SIN: 604 681 684
Protected B when completed
Attach only the documents (schedules, information slips, forms, or receipts) requested to support
any claim or deduction. Keep all other supporting documents.

Step 2 – Total income

As a resident of Canada, you have to report your income from all sources both inside and outside Canada.
The Income Tax and Benefit Guide may have additional information for certain lines.

Employment income (box 14 of all T4 slips) 10100

Tax-exempt income for emergency services volunteers
(See line 10100 in the guide.) 10105
Commissions included on line 10100 (box 42 of all T4 slips) 10120
Wage-loss replacement contributions (See line 10100 in the guide.) 10130
Other employment income 10400
Old age security pension (box 18 of the T4A(OAS) slip) 11300 7,271 67
CPP or QPP benefits (box 20 of the T4A(P) slip) 11400 10,705 92
Disability benefits included on line 11400
(box 16 of the T4A(P) slip) 11410
Other pensions and superannuation (See line 11500 in the guide and complete line 31400 in the
Worksheet for the return.) 11500 20,487 76
Elected split-pension amount (Get and complete Form T1032.) 11600
Universal child care benefit (UCCB) (See the RC62 slip.) 11700

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UCCB amount designated to a dependant 11701
Employment insurance and other benefits (box 14 of the T4E slip) 11900

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Employment insurance maternity and parental benefits and provincial
parental insurance plan benefits 11905

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Taxable amount of dividends (eligible and other than eligible) from taxable Canadian corporations
(Complete the Worksheet for the return.)
A 12000
Taxable amount of dividends other than eligible dividends, included on
Y
N C
line 12000, from taxable Canadian corporations 12010
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Interest and other investment income (Complete the Worksheet for the return.) 12100 100 58
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Net partnership income: limited or non-active partners only 12200

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Registered disability savings plan income (box 131 of the T4A slip) 12500
Rental income Gross 12599 Net 12600
Taxable capital gains (Complete Schedule 3.) 12700
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Support payments received Total 12799 Taxable amount 12800

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RRSP income (from all T4RSP slips) 12900

Other income Specify: 13000
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Taxable scholarship, fellowships, bursaries, and artists' project grants 13010

Self-employment income
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Business income Gross 13499 Net 13500

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Professional income Gross 13699 Net 13700

Commission income Gross 13899 Net 13900
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Farming income Gross 14099 Net 14100

Fishing income Gross 14299 Net 14300
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Workers' compensation benefits (box 10 of the T5007 slip) 14400

Social assistance payments 14500
Net federal supplements (box 21 of the T4A(OAS) slip) 14600

Add lines 14400, 14500, and 14600. (See line 25000 in Step 4.) 14700
Add lines 10100, 10400 to 11400, 11500 to 11700, 11900, 12000,
12100 to 12500, 12600, 12700, 12800, 12900 to 13010, 13500, 13700,
13900, 14100, 14300, and 14700. This is your total income. 15000 38,565 93

5006-R Page 3
Name: richard moszynski SIN: 604 681 684
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Step 3 – Net income

Enter your total income from line 15000 from the previous page. 15000 38,565 93
Pension adjustment (box 52 of all T4 slips and
box 034 of all T4A slips) 20600
Registered pension plan deduction
(box 20 of all T4 slips and box 032 of all T4A slips) 20700
RRSP deduction (See Schedule 7 and attach receipts.) 20800
Pooled registered pension plan (PRPP) employer
contributions (amount from your
PRPP contribution receipts) 20810

Deduction for elected split-pension amount (Get and complete Form T1032.) 21000 3,387 46

Annual union, professional, or like dues (receipts and box 44 of all T4 slips) 21200

Universal child care benefit repayment (box 12 of all RC62 slips) 21300
Child care expenses (Get and complete Form T778.) 21400

Disability supports deduction (Get and complete Form T929.) 21500

Business investment loss

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Gross 21699 Allowable deduction 21700
Moving expenses (Get and complete Form T1-M.) 21900

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Support payments made
Total 21999 Allowable deduction 22000

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Carrying charges and interest expenses (Complete the Worksheet for the
return.)
A 22100
Deduction for CPP or QPP contributions on self-employment and other
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earnings (Complete Schedule 8 or get and complete Form RC381,
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whichever applies.) 22200
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Deduction for CPP or QPP enhanced contributions on employment income

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(Complete Schedule 8 or get and complete Form RC381, whichever applies.) 22215
Exploration and development expenses (Get and complete Form T1229.) 22400
Other employment expenses 22900
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Clergy residence deduction (Get and complete Form T1223.) 23100

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Other deductions Specify: 23200

Add lines 20700, 20800, 21000 to 21500, 21700, 21900, 22000, and
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22100 to 23200. 23300 3,387 46 3,387 46

Line 15000 minus line 23300 (if negative, enter "0") This is your net income before adjustments. 23400 35,178 47
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Social benefits repayment (If you reported income at line 11900 and the amount at line 23400 is
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greater than $66,375, see the repayment chart on the back of your T4E slip. If you reported income
on lines 11300 or 14600, and the amount at line 23400 is greater than $77,580, complete the chart
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for line 23500 on the Worksheet for the return. Otherwise, enter "0".) 23500
Line 23400 minus line 23500 (if negative, enter "0") This is your net income. 23600 35,178 47
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Name: richard moszynski SIN: 604 681 684
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Step 4 – Taxable income

Canadian Forces personnel and police deduction (box 43 of all T4 slips) 24400
Security options deductions 24900
Other payments deduction (Claim the amount from line 14700, unless it
includes an amount at line 14600. If so, see line 25000 in the guide.) 25000
Limited partnership losses of other years 25100
Non-capital losses of other years 25200
Net capital losses of other years 25300
Capital gains deduction (Get and complete Form T657.) 25400

Northern residents deductions (Get and complete Form T2222.) 25500

Additional deductions Specify: 25600
Add lines 24400 to 25600. 25700
Line 23600 minus line 25700 (if negative, enter "0") This is your taxable income. 26000 35,178 47

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5006-R Page 5
Name: richard moszynski SIN: 604 681 684
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Step 5 – Federal tax (formerly Schedule 1)

Part A – Federal non-refundable tax credits
Basic personal amount claim $12,069 30000 12,069 00 1
Age amount (if you were born in 1954 or earlier)
(Complete the Worksheet for the return.) (maximum $7,494) 30100 7,494 00 2
Spouse or common-law partner amount (Complete Schedule 5.) 30300 3
Amount for an eligible dependant (Complete Schedule 5.) 30400 4
Canada caregiver amount for spouse or common-law partner, or eligible dependant
age 18 or older (Complete Schedule 5.) 30425 5
Canada caregiver amount for other infirm dependants age 18 or older
(Complete Schedule 5.) 30450 6
Canada caregiver amount for infirm children under 18 years of age
Enter the number of children for whom you are claiming this amount. 30499 x $2,230 = 30500 7
Base CPP or QPP contributions:
through employment income
(Complete Schedule 8 or get and complete Form RC381, whichever applies.) 30800 8
on self-employment and other earnings
(Complete Schedule 8 or get and complete Form RC381, whichever applies.) 31000 9
Employment insurance premiums:
through employment from box 18 and box 55 of all T4 slips (maximum $860.22) 31200 10

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on self-employment and other eligible earnings (Complete Schedule 13.) 31217 11
Volunteer firefighters' amount 31220 12

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Search and rescue volunteers' amount 31240 13
Canada employment amount (Enter $1,222 or the total of your employment income you reported on

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lines 10100 and 10400, whichever is less.) 31260 14
Home buyers' amount
A 31270 15
Home accessibility expenses (Complete the Worksheet for the return.)
Y (maximum $10,000) 31285 16
N C
Adoption expenses 31300 17
B
Pension income amount (Complete the Worksheet for the return.) (maximum $2,000) 31400 2,000 00 18
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Disability amount (for self)

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(Claim $8,416 or if you were under 18 years of age, complete the Worksheet for the return.) 31600 19
Disability amount transferred from a dependant (Complete the Worksheet for the return.) 31800 20
Interest paid on your student loans (See Guide P105.) 31900 21
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Your tuition, education, and textbook amounts (Complete Schedule 11.) 32300 22
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Tuition amounts transferred from a child 32400 23

Amounts transferred from your spouse or common-law partner (Complete Schedule 2.) 32600 24
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Medical expenses for self, spouse or common-law partner, and

your dependent children born in 2002 or later 33099 25
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Enter $2,352 or 3% of line 23600, whichever is less. 1,055 35 26

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Subtotal (if negative, enter "0") 27

Allowable amount of medical expenses for other dependants
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(Complete the Worksheet for the return.) 33199 28

Add lines 27 and 28. 33200 29
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Add lines 1 to 24, and line 29. 33500 21,563 00 30

Federal non-refundable tax credit rate 15% 31
Multiply line 30 by line 31. 33800 3,234 45 32
Donations and gifts (Complete Schedule 9.) 34900 431 65 33
Add lines 32 and 33.
Enter this amount on line 46 on the next page. Total federal non-refundable tax credits 35000 3,666 10 34

5006-R Page 6
Name: richard moszynski SIN: 604 681 684
Protected B when completed
Part B – Federal tax on taxable income
Enter your taxable income from line 26000. 35,178 47 35

Complete the appropriate column more than more than more than
depending on the amount on line 35. $47,630 but $95,259 but $147,667 but
If the amount on line 35 is: $47,630 not more not more not more more
or less than $95,259 than $147,667 than $210,371 than $210,371
Enter the amount from line 35. 35,178 47 36
0 00 47,630 00 95,259 00 147,667 00 210,371 00 37
Line 36 minus line 37
(cannot be negative) 35,178 47 38
15% 20.5% 26% 29% 33% 39
Multiply line 38 by line 39. 5,276 77 40
0 00 7,145 00 16,908 00 30,535 00 48,719 00 41

Add lines 40 and 41. 5,276 77 42

Part C – Net federal tax

Enter the amount from line 42. 5,276 77 43
Federal tax on split income (Get and complete Form T1206.) 40424 44
Add lines 43 and 44. 40400 5,276 77 5,276 77 45

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Enter your total federal non-refundable tax credits
from line 37 on the previous page. 35000 3,666 10 46

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Federal dividend tax credit (See line 40425 in the guide.) 40425 47
Minimum tax carryover (Get and complete Form T691.) 40427 48

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Add lines 46, 47, and 48. 3,666 10 3,666 10 49
Line 45 minus line 49 (if negative, enter "0")
A Basic federal tax 42900 1,610 67 50
Federal foreign tax credit (Get and complete Form T2209.)
Y 40500 51
N C
Subtotal: Basic federal tax minus foreign tax credits 1,610 67
B
Recapture of investment tax credit (attach form T2038(IND))
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Subtotal plus recapture of investment tax credit (if negative, enter "0") Federal tax 40600 1,610 67 52
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Federal logging tax credit

Federal tax minus logging tax credit (if negative, enter "0") Total federal tax 1,610 67
Total federal political contributions
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(attach receipts) 40900 53

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Federal political contribution tax credit (see Help) (maximum $650) 41000 54
Investment tax credit (attach Form T2038(IND)) 41200 55
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Labour-sponsored funds tax credit (See lines 41300 and 41400 in the guide.)
Net cost of shares of a
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provincially registered fund 41300 Allowable credit 41400 56

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Add lines 54, 55, and 56. 41600 57

Total federal tax minus line 57 (if negative, enter "0"). 41700 1,610 67 58
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Canada workers benefit advance payments received (box 10 of the RC210 slip) 41500 59
Special taxes (See line 41800 in the guide.) 41800 60
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Add lines 58, 59, and 60.

Enter this amount on line 42000 on the next page. Net federal tax 42000 1,610 67 61

Step 6 – Provincial or territorial tax

Complete Form 428 to calculate your provincial tax.

5006-R Page 7
Name: richard moszynski SIN: 604 681 684
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Step 7 – Refund or balance owing
Net federal tax: enter the amount from line 61 from the previous page. 42000 1,610 67
CPP contributions payable on self-employment and other earnings
(Complete Schedule 8 or get and complete Form RC381, whichever applies.) 42100
Employment insurance premiums payable on self-employment and other eligible earnings
(Complete Schedule 13.) 42120
Social benefits repayment (amount from line 23500) 42200
Provincial or territorial tax (Attach Form 428, even if the result is "0".) 42800 1,042 68
Add lines 42000, 42100, 42120, 42200, and 42800.
This is your total payable. 43500 2,653 35
Total income tax deducted (amounts from all Canadian slips) 43700 5,130 09
Refundable Quebec abatement (See line 44000 in the guide.) 44000
CPP overpayment (See line 30800 in the guide.) 44800
Employment insurance overpayment (See line 45000 in the guide.) 45000
Climate action incentive (Complete Schedule 14.) 45110 336 00
Refundable medical expense supplement (Complete the Worksheet for the return.) 45200
Canada workers benefit (CWB) (Complete Schedule 6.) 45300
Refund of investment tax credit (Get and complete Form T2038(IND).) 45400
Part XII.2 trust tax credit
(box 38 of all T3 slips and box 209 of all T5013 slips) 45600
Employee and partner GST/HST rebate

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(Get and complete Form GST370.) 45700
Eligible educator school supply tax credit

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Supplies expenses (maximum $1,000) 46800 x 15% = 46900
Tax paid by instalments 47600

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Provincial or territorial credits (Complete Form 479, if it applies.) 47900
Add lines 43700 to 45700, and 46900 to 47900.
A
These are your total credits. 48200
Y 5,466 09 5,466 09
N C
Line 43500 minus line 48200 This is your refund or balance owing. (2,812 74)
B
If the result is negative, you have a refund. If the result is positive, you have a balance owing.
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Enter the amount below on whichever line applies.

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Generally, we do not charge or refund a difference of $2 or less.

Refund 48400 2,812 74 Balance owing 48500
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For more information on how to receive your refund For more information on how to make your payment, see
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by direct deposit, see line 48400 in the guide or go line 48500 in the guide or go to canada.ca/payments.
to canada.ca/cra-direct-deposit. Your payment is due no later than April 30, 2020.
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Ontario opportunities fund Amount from line 48400 above 2,812 74 1

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You can help reduce Ontario's debt by completing this area to Your donation to the
donate some or all of your 2019 refund to the Ontario Ontario opportunities fund 46500 2
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opportunities fund. Please see the provincial pages for details. Net refund (line 1 minus line 2) 46600 2,812 74 3
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I certify that the information given on this return and in any documents If this return was completed by a tax professional, tick the
attached is correct and complete and fully discloses all my income. applicable box and provide the following information:
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Sign here 49000 Was a fee charged? Yes 1 No 2

It is a serious offence to make a false return. 48900 EFILE number (if applicable):
Telephone number: 8072743180 Name of tax professional:
Date: Telephone number:

Personal information (including the SIN) is collected for the purposes of the administration or enforcement of the Income Tax Act and related programs and
activities including administering tax, benefits, audit, compliance, and collection. The information collected may be used or disclosed for purposes of other
federal acts that provide for the imposition and collection of a tax or duty. It may also be disclosed to other federal, provincial, territorial or foreign government
institutions to the extent authorized by law. Failure to provide this information may result in interest payable, penalties or other actions. Under the Privacy Act,
individuals have the right to access their personal information, request correction, or file a complaint to the Privacy Commissioner of Canada regarding the
handling of the individual’s personal information. Refer to Personal Information Bank CRA PPU 005 on Info Source at canada.ca/cra-info-source.
Do not use 48600
this area 48700 48800

5006-R Page 8 Canada Revenue Agency Approval # : RC-19-107

Name: richard moszynski SIN: 604 681 684
Protected B when completed
T1-2019 Donations and Gifts Schedule 9

Complete this schedule and attach it to your return to claim an amount on line 34900 of your return.

For more information, see Pamphlet P113, Gifts and Income Tax.

Eligible amount of charitable donations

Include at lines 1 to 4 all the eligible amounts of donations you want to claim this year. This includes the eligible amount of
donations that either you or your spouse or common-law partner made in 2019 or in any of the previous 5 years that have
not been claimed before. Remember, you may have charitable donations shown on your T4 and T4A slips. If you are
claiming gifts made to a charity in the United States, see Pamphlet P113.

Donations made to registered charities, registered Canadian amateur athletic associations,

and registered Canadian low-cost housing corporations for the aged 1,585 00 1
Donations made to government bodies (government of Canada, a province, a territory, registered
municipalities in Canada, or registered municipal or public bodies performing a function of
government in Canada) 32900 2
Donations made to registered universities outside Canada 33300 3

Donations made to the United Nations, its agencies, and certain registered foreign charitable organizations 33400 4

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Add lines 1 to 4. Total eligible amount of charitable donations 1,585 00 5

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Donations limit

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Enter your net income from line 23600 of your return. 35,178 47 6 x 75% = 26,383 85 7
A
Y
If line 5 is less than line 7, enter the amount from line 5 on line 13 below and continue on line 14.
N C
Otherwise, complete lines 8 to 12, before continuing on line 13.
B
Gifts of depreciable property
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(from Chart 2 in Pamphlet P113) 33700 8

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Gifts of capital property

(from Chart 1 in Pamphlet P113) 33900 9
Add lines 8 and 9. 10 x 25% = 11
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Enter the total of lines 7 and 11 or the amount on line 23600

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of your return, whichever is less. Total donations limit 26,383 85 12

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Donations and gifts

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Allowable charitable donations. If you did not complete lines 8 to 12, enter the amount from line 5.
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Otherwise, enter the amount from line 5 or line 12, whichever is less. 34000 1,585 00 13
Eligible amount of cultural and ecological gifts (See Pamphlet P113.) 34200 14
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Add lines 13 and 14. 1,585 00 15

Enter $200 or the amount from line 15, whichever is less. 200 00 16
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Line 15 minus line 16. 1,385 00 17

Continue on the next page.

5000-S9 Page 1 of 2
Name: richard moszynski SIN: 604 681 684
Protected B when completed
Schedule 9

If your taxable income is less than $210,371, enter "0" on line 26 and continue on line 28.
Otherwise, complete lines 18 to 27, before continuing on line 28.

Enter the amount from line 17 from the previous page. 18

Total of your donations made before 2016 included on
lines 5 and 14, to a maximum of the amount on line 15
from the previous page. 34210 19
Line 18 minus line 19 (if negative, show it in brackets) 20
Enter the amount from line 16 or line 19,
whichever is less. 21
Add lines 20 and 21. 22

Enter your taxable income from line 26000 of your return. 23

Income threshold 210,371 00 24
Line 23 minus line 24 (if negative enter "0") 25
If you did not complete lines 18 to 25, enter "0".
Otherwise, enter the amount from line 22 or line 25,
whichever is less. 26 x 33% = 27
If you did not complete lines 18 to 27, enter the amount

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from line 17. Otherwise, enter the result of line 17
minus line 26. 1,385 00 28 x 29% = 401 65 29

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Enter the amount from line 16. 200 00 30 x 15% = 30 00 31
Add lines 27, 29, and 31.

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Enter this amount on line 34900 of your return. Donations and Gifts 431 65 32
A
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N C
B
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See the privacy notice on your return.

5000-S9 Page 2 of 2
Name: richard moszynski SIN: 604 681 684
Form ON428
2019
Ontario Tax Protected B when completed

This is Step 6 in completing your return. Complete this form and attach a copy to your return.
Claim only the credits that apply to you.

Part A – Ontario non-refundable tax credits

For internal use only 56050

Basic personal amount Claim $10,582 58040 10,582 00 1
Age amount (if born in 1954 or earlier)
(use Worksheet ON428) (maximum $5,166) 58080 5,166 00 2
Spouse or common-law partner amount
Base amount 9,883 00 3
Your spouse's or common-law partner's
net income from line 23600 of their return 35,994 73 4
Line 3 minus 4 (if negative, enter "0") (maximum $8,985) 58120 5
Amount for an eligible dependant
Base amount 9,883 00 6
Your eligible dependant's net income
from line 23600 of their return 7

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Line 6 minus line 7 (if negative, enter "0") (maximum $8,985) 58160 8
Add lines 1, 2, 5, and 8. 15,748 00 9

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Ontario caregiver amount
(use Worksheet ON428) 58185 10

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CPP and QPP contributions:
Amount from line 30800 of your return
A 58240 11
Amount from line 31000 of your return
Y 58280 12
N C
Employment insurance premiums:
B
Amount from line 31200 of your return 58300 13
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Amount from line 31217 of your return 58305 14

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Adoption expenses (maximum $12,910) 58330 15

Pension income amount (maximum $1,463) 58360 1,463 00 16
Disability amount (for self)
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(Claim $8,549, or if you were under 18 years of age, use Worksheet ON428.) 58440 17
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Disability amount transferred from a dependant

(use Worksheet ON428) 58480 18
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Interest paid on your student loans

(amount from line 31900 of your return) 58520 19
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Your unused tuition and education amounts

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(attach Schedule ON(S11)) 58560 20

Amounts transferred from your spouse or common-law partner
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(attach Schedule ON(S2)) 58640 21

Add lines 9 to 21. 17,211 00 22
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Continue on the next page.

5006-C Page 1 of 5
Name: richard moszynski SIN: 604 681 684
Protected B when completed
Form ON428
Part A – Ontario non-refundable tax credits (continued)

Enter the amount from line 22 of the previous page 17,211 00 23

Medical expenses:
(Read line 58689 of your income tax package.) 58689 24
Enter whichever is less:
$2,395 or 3% of the amount on line 23600 of your return 1,055 35 25
Line 24 minus line 25 (if negative, enter "0") 26
Allowable amount of medical expenses for other dependants
(use Worksheet ON428) 58729 27
Add lines 26 and 27. 58769 28
Add lines 23 and 28, plus line 11 of RC269. 58800 17,211 00 29
Ontario non-refundable tax credit rate 5.05% 30
Multiply line 29 by line 30. 58840 869 16 31

Donations and gifts:

Amount from line 16
of your federal Schedule 9 200 00 x 5.05% = 10 10 32
Amount from line 16
of your federal Schedule 9 1,385 00 x 11.16% = 154 57 33

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Add lines 32 and 33. 58969 164 67 164 67 34
Add lines 31 and 34.

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Enter this amount on line 47. Ontario non-refundable tax credits 61500 1,033 83 35

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Part B – Ontario tax on taxable income
A
Y
N C
Enter your taxable income from line 26000 of your return. 35,178 47 36
B
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Use the amount from line 36 to decide which column to complete.

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Line 36 is more than Line 36 is more than Line 36 is more than

Line 36 is $43,906 but not $87,813 but not $150,000 but not Line 36 is more
SE

$43,906 or less more than $87,813 more than $150,000 more than $220,000 than $220,000
U

Amount from line 36 35,178 47 37

Line 37 minus line 38 0 00 43,906 00 87,813 00 150,000 00 220,000 00 38
D
T

(cannot be negative) 35,178 47 39

5.05% 9.15% 11.16% 12.16% 13.16% 40
O

Multiply line 39 by line 40. 1,776 51 41

N

Add lines 41 and 42. 0 00 2,217 00 6,235 00 13,175 00 21,687 00 42

Ontario tax on
O

taxable income 1,776 51 43

D

Continue on the next page.

5006-C Page 2 of 5
Name: richard moszynski SIN: 604 681 684
Protected B when completed
Form ON428
Part C – Ontario tax

Enter your Ontario tax on taxable income from line 43 of the previous page. 1,776 51 44
Enter your Ontario tax on split income from Form T1206. 61510 45
Add lines 44 and 45. 1,776 51 46
Enter your Ontario non-refundable tax credits from line 35 of the previous page. 1,033 83 47
Line 46 minus line 47 (if negative, enter "0") 742 68 48

Ontario minimum tax carryover:

Amount from line 48 above 742 68 49
Enter the Ontario dividend tax credit calculated for line 61520
from your Worksheet ON428. 50
Line 49 minus line 50 (if negative, enter "0") 742 68 51

Amount from line 40427 of your return × 33.67% = 52

Enter whichever is less: amount from line 51 or 52. 61540 53
Line 48 minus line 53 (if negative, enter "0") 742 68 54

Ontario surtax
Amount from line 54 above 742 68 55

IL
Amount from line 45 above 56
Line 55 minus line 56 (if negative, enter "0") 742 68 57

TE
A
Complete lines 58 to 60 if the amount on line 57 is more than $4,740.

M
If the amount is less than $4,740, enter "0" on line 60 and continue on line 61.
A
(Line 57 742 68 – $4,740) × 20% (if negative, enter "0") =
Y 58
N C
(Line 57 742 68 – $6,067) × 36% (if negative, enter "0") = 59
B
Add lines 58 and 59. 60
I

Add lines 54 and 60. 742 68 61

D
PL

Ontario dividend tax credit:

Amount from line 50 above 61520 62
SE

Line 61 minus line 62 (if negative, enter "0") 742 68 63

U

Ontario additional tax for minimum tax purposes

D
T

If you entered an amount on line 98 of Form T691, enter the additional tax for minimum tax
purposes calculated for line 64 from your Worksheet ON428. 64
O

Add lines 63 and 64. 742 68 65

N

Continue on the next page.

O
D

5006-C Page 3 of 5
Name: richard moszynski SIN: 604 681 684
Protected B when completed
Form ON428
Part C – Ontario tax (continued)
Enter the amount from line 65 of the previous page. 742 68 66

Ontario tax reduction

Enter "0" on line 73 if any of the following applies to you:

• You were not a resident of Canada at the beginning of the year.
• You were not a resident of Ontario on December 31, 2019.
• There is an amount on line 64.
• The amount on line 66 is "0".
• Your return is filed for you by a trustee in bankruptcy.
• You are not claiming an Ontario tax reduction.

If none of the above applies to you, complete lines 67 to 73 to calculate your Ontario tax reduction.

X Check this box to claim the tax reduction on your return

Basic reduction 244 00 67

IL
If you had a spouse or common-law partner on December 31, 2019, only
the individual with the higher net income can claim the amounts

TE
A
the individual with the higher net income can claim the amounts

M
Reduction for dependent children born in 2001 or later
Number of dependent children 60969
A
× $452 = 68
Reduction for dependants with a mental or physical impairment
Y
N C
Number of dependants 60970 × $452 = 69
B
Add lines 67, 68, and 69. 244 00 70
I

Amount from line 70 above 244 00 x2= 488 00 71

D
PL

Amount from line 66 above 742 68 72

Line 71 minus line 72
(if negative, enter "0") Ontario tax reduction 73
SE

Line 66 minus line 73 (if negative, enter "0") 742 68 74

U

Ontario foreign tax credit

D
T

Credit calculated from Form T2036 75

Line 74 minus line 75 (if negative, enter "0") 742 68 76
O
N

Low-income individuals and families tax credit

Credit calculated from Schedule ON428–A 62140 77
O

Line 76 minus line 77 (if negative, enter "0") 742 68 78

D

Community food program donation tax credit for farmers

Enter the amount of qualifying donations that have also
been claimed as a charitable donation. 62150 x 25% = 79
Line 78 minus line 79 (if negative, enter "0") 742 68 80

Ontario health premium

Use the chart on the next page to calculate this amount. 300 00 81
Add lines 80 and 81.
Enter the result on line 42800 of your return. Ontario tax 1,042 68 82

Continue on the next page.

5006-C Page 4 of 5
Name: richard moszynski SIN: 604 681 684
Protected B when completed
Form ON428
Part C – Ontario tax (continued)

Ontario Health Premium

Enter your taxable income from line 36 of page 2. 35,178 47 83

Go to the line on the chart below that corresponds to your taxable income from line 83 to determine
your Ontario Health Premium.
Enter the result on line 81 of the previous page.

Taxable income Ontario health premium

not more than $20,000 $0

more than $20,000, but not more than $25,000 - $20,000 = x 6% =

more than $25,000, but not more than $36,000 $300

more than $36,000, but not more than $38,500 - $36,000 = x 6% = + $300 =

IL
more than $38,500, but not more than $48,000 $450

TE
A
more than $48,000, but not more than $48,600 - $48,000 = x 25% = + $450 =

M
more than $48,600, but not more than $72,000
A $600

Y
N C
more than $72,000, but not more than $72,600 - $72,000 = x 25% = + $600 =
B
I

more than $72,600, but not more than $200,000 $750

D
PL

more than $200,000, but not more than $200,600 - $200,000 = x 25% = + $750 =
SE

more than $200,600 $900

U
D
T
O
N
O
D

See the privacy notice on your return.

5006-C Page 5 of 5
Name: richard moszynski SIN: 604 681 684
Schedule ON428-A
Low-income Individuals and Families 2019
Tax Credit Protected B when completed

• To find out if you are eligible for the Low-income individuals and families tax credit, see the "Information for residents of
Ontario" section of your tax package.
• Complete this schedule and attach a copy to your return.

Calculating your maximum allowable credit

Amount from line 10100 of your return 1

Amount from line 10400 of your return 2
Add lines 1 and 2. 3
Applicable rate for 2019 5.05% 4
Multiply line 3 by line 4. (maximum $850) 5

Calculating your adjusted net income

Amount from line 23600 of your return 35,178 47 6

Amount from line 21300 of your return 7

IL
Amount of Registered disability savings plan (RDSP)
income repayment included on line 23200 of your return 8

TE
A
Add lines 6 to 8. 35,178 47 35,178 47 9

M
Amount from line 11700 of your return 10
Amount of RDSP income included on line 12500
A
of your return 11
Y
N C
Add lines 10 and 11. 12
B
Line 9 minus line 12
I

(if negative, enter "0") Your adjusted net income 35,178 47 13

D
PL

If you were single at the end of the year, complete Part A to calculate your credit.
SE

If you had a spouse or common-law partner at the end of the year, complete Part B on the next page.
U
D
T

Part A – Calculating the credit for single individuals

O

Amount from line 5 above (maximum $850) 14

N

Amount from line 13 above 15

Individual income threshold 16
O

Line 15 minus line 16

(if negative, enter "0") 17
D

Applicable rate 10% 18

Multiply line 17 by line 18. 19
Line 14 minus line 19
(if negative, enter "0") 20

Enter this amount on line 62140 of your Form ON428.

Continue on the next page.

5006-A Page 1 of 2
Name: richard moszynski SIN: 604 681 684
Protected B when completed
Schedule ON428-A

Part B – Calculating the credit for individuals with a spouse or common-law partner

Amount from line 23600 of your spouse's

or common-law partner's return 35,994 73 21
Amount from line 21300 of your spouse's
or common-law partner's return 22
Amount of RDSP income repayment included
on line 23200 of your spouse's or common-law
partner's return 23
Add lines 21 to 23. 35,994 73 35,994 73 24

Amount from line 11700 of your spouse's

or common-law partner's return 25
Amount of RDSP income included on line 12500
of your spouse's or common-law partner's return 26
Add lines 25 and 26. 27
Line 24 minus line 27 Your spouse's or common-law
(if negative, enter "0") partner's adjusted net income 35,994 73 28

IL
Amount from line 5 of the previous page (maximum $850) 29

TE
A
Amount from line 13 of the previous page 35,178 47 30
Individual income threshold 30,000 00 31

M
Line 30 minus line 31
(if negative, enter "0")
A 5,178 47 32

Y
N C
Amount from line 30 above 35,178 47 33
B
Amount from line 28 above 35,994 73 34
I

Add lines 33 and 34. Adjusted family net income 71,173 20 35

D
PL

Family income threshold 60,000 00 36

Line 35 minus line 36
(if negative, enter "0") 11,173 20 37
SE
U

Enter whichever is more: amount from line 32 or line 37 above 11,173 20 38

Applicable rate 10% 39
D
T

Multiply line 38 by line 39. 1,117 32 1,117 32 40

Line 29 minus line 40
O

(if negative, enter "0") 41

N

Enter this amount on line 62140 of your Form ON428.

O
D

See the privacy notice on your return.

5006-A Page 2 of 2
Name: richard moszynski SIN: 604 681 684
Protected B when completed
T1-2019 Climate Action Incentive Schedule 14

The climate action incentive (CAI) consists of a basic amount and a supplement for residents of small and rural
communities.

You cannot claim the CAI if any of the following applies to you:
• you were a non-resident of Canada at any time in 2019
• you were confined to a prison or a similar institution for a period of at least 90 days during 2019
• you were exempt from income tax in Canada at any time in 2019 because you were an officer or servant of the government of
another country, such as a diplomat, or a family member who resided with such a person, or an employee of such a person
• you were a person for whom a children's special allowance (CSA) was payable at any time in 2019

Note: If you are completing a return for a person who died before April 1, 2020, you cannot claim the CAI for that person for
the 2019 tax year.

Complete this schedule and attach it to your return to claim the CAI if, on December 31, 2019, you were a resident of
Ontario and you met any of the following conditions:
• you were 18 years of age or older
• you had a spouse or a common-law partner
• you were a parent who lived with your child

IL
Note: If you were married or living in a common-law relationship but your spouse or common-law partner was not an eligible
spouse or common-law partner for the purpose of the CAI or you did not have a qualified dependant, complete this

TE
A
schedule using the instructions as if you did not have an eligible spouse or common-law partner or a qualified dependant.

M
Eligible spouse or common-law partner
A
For the purpose of the CAI, an eligible spouse or common-law partner is a person who meets all of the following conditions:
• was your spouse or common-law partner on December 31, 2019
Y
N C
• was a resident of Canada throughout 2019
B
• was not confined to a prison or a similar institution for a period of at least 90 days during 2019
I

• was not exempt from income tax in Canada at any time in 2019 because they were an officer or servant of the government of
D
PL

another country, such as a diplomat, or a family member who resided with such a person, or an employee of such a person
• was not a person for whom a CSA was payable at any time in 2019
• did not die before April 1, 2020
SE
U

Notes: Either you or your spouse or common-law partner may claim the CAI for the family, but not both of you.
When two individuals in the family reside in different locations, the province of residence for the individual making
D
T

the claim will be used when calculating the CAI for the family.
O

Qualified dependant
N

For the purpose of the CAI, a qualified dependant is a person who meets all of the following conditions:
• was your cohabiting spouse's or your common-law partner's child or a person dependent on either one of you for support on
O

December 31, 2019

• resided with you on December 31, 2019
D

• was under 18 years of age on December 31, 2019

• was a resident of Canada throughout 2019
• was not married or living with a common-law partner on December 31, 2019
• was not a parent who lived with their child on December 31, 2019
• was not confined to a prison or a similar institution for a period of at least 90 days during 2019
• was not exempt from income tax in Canada at any time in 2019 because they were an officer or servant of the government of
another country, such as a diplomat or a family member who resided with such a person, or an employee of such a person
• was not a person for whom a CSA was payable at any time in 2019
• did not die before April 1, 2020

5006-S14 Page 1 of 2
Name: richard moszynski SIN: 604 681 684
Protected B when completed
Schedule 14

Single parents of a qualified dependant

For the purpose of the CAI, if, on December 31, 2019, you did not have a spouse or a common-law partner but you had a
dependant who met all of the conditions for a qualified dependant, claim an amount for that dependant on line 60102. If you
had more than one qualified dependant, enter the number of remaining qualified dependants on line 60103.

Shared custody
Only one claim can be made per child. You cannot split the amount for a qualified dependant with another person.

Supplement for residents of small and rural communities

To claim the CAI supplement for residents of small and rural communities, you must have resided outside of a census
metropolitan area (CMA) on December 31, 2019, as defined by Statistics Canada in the last census they published before
2019.

Therefore, you cannot claim the supplement for residents of small and rural communities if your principal place of
residence was located in one of the following Ontario CMAs: Barrie, Belleville, Brantford, Greater Sudbury, Guelph,
Hamilton, Kingston, Kitchener-Cambridge-Waterloo, London, Oshawa, the Ontario part of Ottawa-Gatineau, Peterborough,
St. Catharines-Niagara, Thunder Bay, Toronto, or Windsor.

For more information on how to determine if you resided outside a CMA, go to canada.ca/census-metropolitan-areas.

IL
TE
A
X Check this box to claim the Climate Action Incentive on your return

M
Step 1 – Calculating your basic climate action incentive
A
Y
N C
Base amount claim $224.00 60100 224 00 1
B
I

Amount for an eligible spouse or common-law partner claim $112.00 60101 112 00 2
D
PL

Amount for a single parent's qualified dependant claim $112.00 60102 3

SE

Amount for qualified dependants

U

(Do not include the qualified dependant Number of qualified

claimed on line 60102 above, if applicable.) dependants 60103 × $56.00 = 4
D
T

Add lines 1 to 4. 336 00 5

O
N

Step 2 – Calculating your supplement for residents of small and rural communities
O

Did you reside outside of a census metropolitan area on

D

December 31, 2019, as defined by Statistics Canada? 60104 Yes 1 No X 2

If yes, continue on line 6. Otherwise, enter the amount from

line 5 on line 7 below.
Enter the amount from line 5. × 10% = 6

Step 3 – Calculating your total climate action incentive

Add lines 5 and 6.

Enter this amount on line 45110 of your return. 336 00 7

See the privacy notice on your return.

5006-S14 Page 2 of 2
Name: richard moszynski SIN: 604 681 684
Protected B when completed

Joint Election to Split Pension Income for 2019

If you are filing electronically, keep this form in case we ask to see it later. If you are filing a paper return, you must complete, sign,
and attach copies of this form to both your return and your spouse or common-law partner's return. The information on the forms
must be the same.

Complete this form if you (the transferring spouse or common-law partner) are electing to split your eligible pension income with
your spouse or common-law partner (the receiving spouse or common-law partner) and if you meet all of the following
conditions:

• You and your spouse or common-law partner were not living separate and apart from each other, because of a breakdown in
your marriage or common-law partnership, at the end of the tax year and for a period of 90 days or more beginning in the tax year.

• You and your spouse or common-law partner were residents of Canada on December 31, 2019 (or on the date of death).

• You received pension income in the tax year qualifying for the pension income amount (see "Retirement income – Summary
table" in Step 2 of the Federal Income Tax and Benefit Guide) or you were 65 years of age or older and received certain
qualifying amounts distributed from a retirement compensation arrangement (Box 17 of your T4A-RCA slips).

Only one joint election can be made for a tax year. If both you and your spouse or common-law partner have eligible pension

IL
income, you need to decide who will act as the transferring spouse or common-law partner electing to allocate part of their eligible
pension income to the other spouse or common-law partner (the receiving spouse or common-law partner).

TE
A
This form needs to be filed by your filing due date for the year. For more information on filing due dates, see the Federal Income

M
Tax and Benefit Guide. We may allow you to make a late or amended election, or revoke an original election, under certain
circumstances. Contact us if you need more information.
A
Y
N C
Do you and your spouse or common-law partner jointly agree
B
to split eligible pension income received in the tax year? Yes X No
I
D
PL

If yes, which partners' pension income will be split? richard Helen

X
SE

Step 1 – Identification
U

Information about you (the transferring spouse or common-law partner)

D
T

Social insurance number

Last name moszynski First name richard 604 681 684
O

Home address
N

98B Boucher Rd 216-55 RR2 Your date of birth

Fort Frances ON Postal code P9A3M3 1946/09/28
O
D

Information about your spouse or common-law partner (the receiving spouse or common-law partner)
Social insurance number
Last name Moszynski First name Helen 616 165 684
Home address Your spouse or common-
98B Boucher Rd 216-55 RR2 law partner's date of birth
Fort Frances ON Postal code P9A3M3 1949/09/08

Is your spouse or common-law partner a non-resident at the end of the year? Yes No X

Continued on the next page

T1032 E (19) Page 1 of 4

Name: richard moszynski SIN: 604 681 684
Protected B when completed
Step 2 – Maximum split-pension amount

To calculate the eligible pension income amount, the transferring spouse or common-law partner must complete line 31400
of the Worksheet for the return found in the Income tax package.

Enter the amount from line A of the transferring spouse's or common-law partner's
Worksheet for the return 68020 20,487 76 A
Enter the amount from box 128 of the transferring spouse's or common-law partner's T4A slip 68025 –
Amount from line 68020 minus the amount from line 68025 = 20,487 76 A.1

Qualifying RCA payments and veteran's benefits

If you were 65 years of age or older on December 31, 2019 (or on the date of death) and received
life annuity payments from a retirement compensation arrangement (RCA) or you received veterans
benefits, complete lines 1 to 4. Otherwise, enter "0" on line B.

Enter the amount from box 17 of the transferring spouse's or

common-law partner's T4A-RCA slips 68026 1

Enter the amount from line 68025 + 2

IL
Add lines 1 and 2 = 3

TE
A
$105,895 minus the amount from line A.1 (if negative, enter "0") 4

M
A
Enter the lesser of lines 3 and 4
Y + B
N C
Add lines A.1 and B = 20,487 76 C
B
I
D
PL

Marital status change

If your marital status changed during the tax year, calculate the eligible pension income for
the period that you were married or living common-law. Otherwise, enter the amount from line C
SE

on line E.
U

Number of months married

D
T

or living common-law 68030 x Amount from line C = D

*
O

Divided by: Number of

months in the tax year
N

* If the transferring spouse or common-law partner is deceased, use the number of months up to and
O

including the month of death.

D

Enter the amount from line D, if it applies. Otherwise, enter the amount from line C. 20,487 76 E
x 50%
Multiply the amount on line E by 50% Maximum split-pension amount = 10,243 88 F

Step 3 – Elected split-pension amount

Enter the amount that you and your spouse or common-law partner decide to jointly elect to be your
split-pension amount for the year. The split-pension amount cannot be more than the amount from Line F. 3,387 46 G

Enter this amount on line 21000 of the transferring spouse's or common-law partner's return
and on line 11600 of the receiving spouse's or common-law partner's return.

Page 2 of 4
Name: richard moszynski SIN: 604 681 684
Protected B when completed

Step 4 – Pension income amount (line 31400)

Part A – Calculate the pension income amount of the transferring spouse or common-law partner

Amount from line A 20,487 76 H

Amount from line G, unless Note 1 below applies – 3,387 46 J
Line H minus line J = 2,000 00 K

Enter $2,000 or the amount from line K, whichever is less, on line 31400 of the transferring
spouse or common-law partner's return.
Note 1
If the transferring spouse or common-law partner entered an amount on line B, complete the
following calculation and enter the result on line J: line G – [((line B – line 2) ÷ line C) × line G]

Part B – Calculate the pension income amount of the receiving spouse or common-law partner

If there is an amount on line 11500 or line 12900 of the receiving spouse's or common-law
partner's return, enter the amount from line A of their Worksheet for the return. Otherwise,
enter "0". L
Amount from line J unless Note 2a below applies + M

IL
Add lines L and M = N

TE
A
Enter $2,000 or the amount from line N, whichever is less, on line 31400 of the receiving spouse's
or common-law partner's return.

M
Note 2a
A
If all of the following conditions apply, read Note 2b below:
Y
N C
B
• the amount on line L is less than $2,000
I

• the receiving spouse or common-law partner was under age 65 on December 31, 2019.
D
PL

• the transferring spouse or common-law partner was age 65 or older and received any:
– RRIF, RRSP, or other annuity payments
– variable pension benefits paid from a money-purchase provision of a registered pension plan
SE

– payment out of a pooled registered pension plan (other than amounts received due to the
U

death of their former spouse or common-law partner)

– veteran's benefits included on line 2 of this form
D
T

Note 2b
O

If Note 2a applies, calculate the amount to enter on line M as follows:

N

(1) Recalculate the amount on line A.1 by deducting any of the following sources of pension income:
O

– RRIF, RRSP, or other annuity payments received by your spouse or common-law partner
– variable pension benefits paid from a money purchase provision of a registered pension plan
D

– any payment out of a pooled registered pension plan (other than amounts received due
to the death of their former spouse or common-law partner)

(2) If the result from (1) above is $4,000 or more, enter on line M the amount from line J.

(3) If the result from (1) above is less than $4,000, recalculate Steps 2 and 3 only using the
result from (1) as the amount for line C. Enter on line M the lesser of the amount from line G or J.

Page 3 of 4
Name: richard moszynski SIN: 604 681 684
Protected B when completed

Step 5 – Income tax deducted (line 43700)

Enter the total tax deducted from the transferring spouse's or common-law partner's pension
income entered on line C* 68040 6,146 33 O

* If the transferring spouse's or common-law partner's information slip(s) include(s) income tax
deducted for both eligible and non-eligible pension income on the same slip, calculate the
proportionate amount of tax deducted to be included at line O for each slip as follows:
(Eligible pension ÷ total of eligible and non-eligible pension) × total tax deducted

Calculate the tax deducted for the elected split-pension amount:

Amount on line O 6,146 33 x Amount from line G 3,387 46

Divided by: Amount from line C 20,487 76 = 68050 1,016 24 P

Part A – Calculate the income tax deducted for the transferring spouse or common-law partner

Total tax deducted from all of the transferring spouse or common-law

partner's slips** 6,146 33 1
Amount from line P – 1,016 24 2

IL
Line 1 minus line 2 = 5,130 09 3

TE
A
Enter the result on line 43700 of the transferring spouse's or common-law partner's return.

M
Part B – Calculate the income tax deducted for the receiving spouse or common-law partner
A
Total tax deducted from all of the receiving spouse or common-law
Y
N C
partner's slips** 1
B
Amount from line P + 2
I

Line 1 plus line 2 = 3

D
PL

Enter the result on line 43700 of the receiving spouse's or common-law partner's return.
SE

** Enter the amount that you would have entered on line 43700 of your return if you did not choose to split your eligible pension income.
U

If you were a resident of Quebec on December 31, 2019, do not include any of your Quebec provincial income tax deducted.
D
T

Step 6 – Joint certification

O
N

By completing this form and signing below, we jointly elect and agree that the split-pension amount entered on line G of
Step 3 will be deducted in computing the net income of the transferring spouse or common-law partner and reported as
O

income by the receiving spouse or common-law partner on our income tax and benefit returns for 2019.
D

We understand that we will be jointly and severally liable for any amounts of tax, interest and penalties that may be owing
as a result of this election.

Date
Signature of transferring spouse or common-law partner

Date
Signature of receiving spouse or common-law partner

It is a serious offence to make a false statement.

See the privacy notice on your return.

Page 4 of 4
Name: richard moszynski SIN: 604 681 684
OTHER
Other Income, Deductions and Credits

Line 11905 - Employment insurance maternity and parental benefits and

provincial parental insurance plan maternity and paternity benefits
The amount of the employment insurance maternity and parental benefits you received in 2019 on this line.
This amount can be found on the letter you received from Employment and Social Development Canada (ESDC).
The amount of provincial parental insurance plan (PPIP) maternity and
parental benefits from box 36 of your T4E slip.
Total to line 11905 of your return

Net Partnership Income - Line 12200

Amount from T5013 slips

Total Net Partnership Income - to line 12200 of your return

Other Income - Line 13000

T4A - Box 018: Lump sum payments
T4A - Box 024: Annuities (non-qualifying)
T4A - Box 123: Revoked Deferred Profit Sharing Plan
T4A - Box 125: Disability benefits from a superannuation or pension plan
T4A - Box 129: Tax deferred cooperative share

IL
T4A - Box 130: Apprenticeship incentive or completion grant
T4A - Box 133: Variable pension benefits

TE
A
T4A - Box 109: Periodic payments from an unregistered plan
T4A - Box 134: Tax-Free Savings Account (TFSA) taxable amount

M
T4A - Box 136: Federal Income Support for Parents of Murdered or Missing Children grant (PMMC)
T4A - Box 028: Other income - Other
A
T4A - Box 030: Patronage allocations due to business purchases
Y
N C
T4A - Box 040: RESP accumulated income payments
B
T4A - Box 042: RESP educational assistance payments
I

T4A - Box 116: Medical travel assistance

D
PL

T4A - Box 117: Loan benefits

T4A - Box 150: Labour Adjustment Benefits Act and Appropriation Acts
T4A - Box 154: Cash award or prize from payer
SE

T4A- Box 194: PRPP Payments

U

T4A-RCA - Statement of distribution from an RCA

T4 - Box 66: Eligible retiring allowances
D
T

T4 - Box 67: Non-eligible retiring allowances

T3 - Box 22: Lump sum pension benefits
O

T3 - Box 25: Foreign non-business income - Other

N

T3 - Box 26: Other income

T4A(P) - Box 18: Death benefit
O

T4A - Box 106: Other income - Death benefits

T3 - Box 35: Eligible death benefits +
D

Less: Tax exemption –

Taxable portion of death benefits =
T4RIF - Box 16: Taxable amounts (non-qualifying)
T4RIF - Box 18: Deemed receipt by annuitant - Deceased
T4RIF - Box 20: Deemed receipt by annuitant - Deregistration
T4RIF - Box 22: Other income
T5013 - Box 114: Other income
Negative balances from Canadian resource expenditure pools (form T1229)
Other income from foreign slips
Other:

Total Other Income - to line 13000 of your return

Page 1 of 3
Name: richard moszynski SIN: 604 681 684
OTHER

Taxable scholarship, fellowships, bursaries, and artists' project grants - Line 13010

T4A - Box 105: Other income - Scholarships

Less: Basic exemption –
Less: Tax exemption for full-time education –
Less: Tax exemption for part-time education –
Other taxable scholarships, grants, etc. –
Taxable portion of scholarships - to line 13010 of your return =

Other Deductions - Line 23200

Undeducted and excess RRSP contributions (line 13, Form T746)

Undeducted RRSP contributions withdrawn (using form T3012A)
Legal or accounting expenses to appeal income tax assessments or respond to CRA reviews
Legal expenses to make child-support non-taxable*
Deduction under section 20(11)
Deduction under section 20(12)
Canada or Québec pension plan benefits paid back
Old age security paid back (Box 20 of T4A(OAS) slip)

IL
Net federal supplements paid back
Employment insurance benefits paid back (Box 30 of T4E slip)

TE
A
Registered disability savings plan (RDSP) income repayment
Scholarships paid back

M
Shareholder's loan amounts paid back
Canadian motion picture film and videotape write-offs
A
RCA deductions under subsection 60(t) and 60(u)
Y
N C
Split income (from Form T1206)
B
T4RIF - Box 22: Other deductions
I

T4RSP - Box 28: Other deductions

D
PL

Depletion allowances (from Form T1229)

Transfers to an RPP, an RRIF or an annuity
Deduction for transfers to a registered disability savings plan (RDSP)
SE

Post-death decrease in the value of an unmatured RRSP or a RRIF

U

Tax Exempt income for Canadian Indians from T4A(P) slip

Other:
D
T

Total Other Deductions - to line 23200 of your return

O
N

* Legal fees paid to collect late support payments, to establish the amount of support payments or to try to get an increase in support payments
should be claimed on line 22100. Please see Schedule 4 to enter these amounts.
O
D

Additional Deductions - Line 25600

Non-taxable tuition assistance (Box 21 of T4E slip)

Tuition assistance for adult basic education (Box 196 T4A slip)
Vow of perpetual poverty
Exempt portion (15%) of U.S. social security benefits
Exempt portion (50%) of U.S. social security benefits
Other income exempt under a tax treaty
Other income exempt under a tax treaty - from slips
Employment with a prescribed international organization
Other:
Total Additional Deductions - to line 25600 of your return

Page 2 of 3
Name: richard moszynski SIN: 604 681 684
OTHER

Total Income Tax Deducted - Line 43700

From all information slips 6,146 33

Plus T1032 line P - pension transferee
Subtotal 6,146 33
Less T1032 line P - pensioner 1,016 24
Total 5,130 09

IL
TE
A
M
A
Y
N C
B
I
D
PL
SE
U
D
T
O
N
O
D

Page 3 of 3
Name: richard moszynski SIN: 604 681 684
PENSION
Pension Income Worksheet

Pension Income Amount

Amount from line 11500 of your income tax return 20,487 76 1
Enter the deduction you claimed at line 25600 for the tax
exempt portion of U.S. social security benefits received 2
Enter any other foreign pension income from line 11500
that you deducted on line 25600 of your return + 3
Enter any income from a U.S. Individual Retirement
Account (IRA) included on line 11500 of your return + 4
Excess amounts from a RRIF or PRPP included on
line 11500 and transferred to an RRSP, PRPP,
another RRIF, or an annuity. + 5
Add lines 2, 3, 4, and 5 = - 6
Line 1 minus 6 = 20,487 76 7
Annuity payments from line 12900 of your return (box 16 of your T4RSP slip)
only if you were age 65 or older on December 31, 2019,
or you received the payments because of the death of
your spouse or common-law partner + 8
Add lines 7 and 8 = 20,487 76 A
Eligible split-pension amount transferred to your spouse or common-law partner - 3,387 46 9

IL
Line A minus 9 = 17,100 30 10
Eligible split-pension amount transferred from your spouse or common-law partner + 11

TE
A
Add lines 10 and 11 = 17,100 30 12
Maximum Credit 2,000 00 13

M
The lesser of line 12 and line 13
A
Pension Income Amount (to line 31400 of your return) 2,000 00 14

Y
N C
B
Joint election to split pension income - Information about your spouse or common-law partner (if applicable)
I

Your spouse or common-law partner's date of birth 1949/09/08 15

D
PL

Is your spouse or common-law partner a non-resident at the end of the year? Yes No X
Enter the amount from line A of their T1032 form 20,487 76 16
Enter the amount from line O of their T1032 form 6,146 33 17
SE

Québec provincial tax withheld, on T1032 line O, as pension transferee 17b

U

Enter the amount from box 68026 of their T1032 form 18

Enter the total amount from box 128 of their T4A slips 19
D
T

Enter the following amounts included on line A of their T1032 form (other than
O

amounts received due to the death of their spouse or common-law partner).

N

Line 19 of their T2205 form 20

O

Enter the following amounts if your spouse is 65 years or older on December 31, 2019
and you are 64 years or younger
D

Total amounts from box 16 of all their T4RIF slips + 21

Total amounts from box 20 of all their T4RIF slips + 22
Total amounts from box 22 of all their T4RIF slips + 23
Total amounts from box 19 of all their T5 slips + 24
Total amounts from box 024 of all their T4A slips + 25
Total amounts from box 133, of all their T4A slips + 26
Total amounts from box 16 of all their T4RSP slips + 27
Total of lines 21 to 27 less line 20 = 28
Name: richard moszynski SIN: 604 681 684
Protected B when completed
Principal Residence Designation Worksheet

Complete this worksheet if you disposed of a property (or properties) in the current tax year for which you are claiming a principal residence
exemption. Generally, you can only designate one property as your principal residence for any specific year, except where you sell
a principal residence and buy another in the same year. Make sure to visit the form T2091 and/or T1255 to designate the number of years your
residence was your principal residence. For residents of Québec, refer also to TP-274-V.

Questions related to your Questions related to a disposition to your

Address portion of the disposition spouse/partner (if applicable)

Apt No Street No Street name or PO Box Adjusted cost base at the time of disposition Did your spouse/partner also dispose of this property
(Note 1) (if applicable)? Yes No
City
Proceeds of disposition Is all or part of the disposition going to your spouse/partner?
Prov./Terr. Postal code Country code (3 letters) Yes No

Lot number Was this your principal residence for all the years If YES, are you electing out of the automatic rollover on
since acquisition? Yes No disposition of capital property to a spouse/partner?
Yes No X

IL
Year of acquisition
Was this a disposition as a consequence of death? If part of the disposition is going to someone other than your

TE
A
Yes No X spouse/partner, enter the percentage that is going to your
spouse/partner:

M
Apt No Street No Street name or PO Box
A
Adjusted cost base at the time of disposition Did your spouse/partner also dispose of this property
(Note 1)

Y (if applicable)? Yes No

N C
City
B
Proceeds of disposition Is all or part of the disposition going to your spouse/partner?
I

Prov./Terr. Postal code Country code (3 letters) Yes No

D
PL

Lot number Was this your principal residence for all the years If YES, are you electing out of the automatic rollover on
since acquisition? Yes No disposition of capital property to a spouse/partner?
SE

Yes No X
U

Year of acquisition
Was this a disposition as a consequence of death? If part of the disposition is going to someone other than your
D
T

Yes No X spouse/partner, enter the percentage that is going to your

O

spouse/partner:
N

Apt No Street No Street name or PO Box Adjusted cost base at the time of disposition Did your spouse/partner also dispose of this property
(Note 1) (if applicable)? Yes No
O

City
Proceeds of disposition Is all or part of the disposition going to your spouse/partner?
D

Prov./Terr. Postal code Country code (3 letters) Yes No

Lot number Was this your principal residence for all the years If YES, are you electing our of the automatic rollover on
since acquisition? Yes No disposition of capital property to a spouse/partner?
Yes No X
Year of acquisition
Was this a disposition as a consequence of death? If part of the disposition is going to someone other than your
Yes No X spouse/partner, enter the percentage that is going to your
spouse/partner:

Note 1: Don't take into account any increase to the adjusted cost base as a result of the election from 1994.

See the privacy notice on your return.

Name: richard moszynski SIN: 604 681 684

IL
TE
A
M
A
Y
N C
B
I
D
PL
SE
U
D
T
O
N
O
D