Jean 2021

Canada Revenue Agence du revenu Protected B when completed
Agency du Canada
Income Tax and Benefit Return
T1 2021
If this return is for a deceased person, enter their information on this page.
Attach to your paper return only the documents that are requested to support your deduction, claim, or expense. Keep all other documents
in case the Canada Revenue Agency (CRA) asks to see them later. See the guide for more information about supporting documents.
Step 1 – Identification and other information

ON 7
Identification Social insurance

First name Last name number (SIN) Marital status on
Jean Pozzobon 415 251 586 December 31, 2021:
Care of
Date of birth 3. Widowed
Apt. No. No./Street (Year Month Day)
16 Algoma Street 1938/02/03
PO Box, RR
If this return is for
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City Prov./Terr. Postal code a deceased person,
Etobicoke ON M8Y 1C3 enter the date of death
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A
(Year Month Day)
Email Address
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By providing an email address, you are registering to
A
receive email notifications from the CRA and agree to
Y
Your language of correspondence: English Français
N C
the Terms of use in Step 1 of the guide. Votre langue de correspondance : X
B
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D
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Residence information
If you became a resident of Canada
Your province or territory of residence on December 31, 2021: in 2021 for income tax purposes, (Month Day)
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Ontario enter your date of entry:

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Your current province or territory of residence if it is different

than your mailing address above: If you ceased to be a resident
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of Canada in 2021 for income

Province or territory where your business had a permanent tax purposes, enter your (Month Day)
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establishment if you were self-employed in 2021: date of departure:

N
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Your spouse's or common-law partner's information

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Their first name Their SIN
Tick this box if they were self-employed in 2021. 1

Net income from line 23600 of their return to claim certain credits (even if the amount is "0")
Amount of universal child care benefit (UCCB) from line 11700 of their return
Amount of UCCB repayment from line 21300 of their return
Do not use this area.
Do not use
this area. 17200 17100
5006-R E (21) Page 1 of 8
Name: Jean Pozzobon SIN: 415 251 586 Printed: 2022/04/16
Protected B when completed
Step 1 – Identification and other information (continued)
Elections Canada
For more information, see "Elections Canada" in Step 1 of the guide.
A) Do you have Canadian citizenship?
If yes, go to question B. If no, skip question B. 1 X Yes 2 No
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 14 to 17 years of age, the Register of Future Electors? 1 X Yes 2 No
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
and your eligibility to vote is confirmed. 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 Electors to provide youth with educational information about the electoral process.
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Indian Act – Exempt income
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A
Tick this box if you have income that is exempt under the Indian Act.
For more information about this type of income, go to canada.ca/taxes-indigenous-peoples. 1
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A
If you ticked the box above, complete Form T90, Income Exempt from Tax under the Indian Act, so that the CRA can
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calculate your Canada workers benefit for the 2021 tax year, if applicable, and your family’s provincial or territorial benefits.
N C
The information you provide on Form T90 will also be used to calculate your Canada training credit limit for the 2022 tax year.
B
daf
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Foreign property
Did you own or hold specified foreign property where the total cost amount of all such property,
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at any time in 2021, was more than CAN$100,000? 26600 1 Yes 2 X No

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If yes, complete Form T1135, Foreign Income Verification Statement. There are substantial penalties for not filing
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Form T1135 by the due date. For more information, see Form T1135.
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N
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5006-R E (21) Page 2 of 8

Complete only the lines that apply to you, unless stated otherwise. You can find more information about the lines on this return
by calling 1-800-959-8281 or by going to canada.ca/line-xxxxx and replacing "xxxxx" with any 5-digit line number from this
return. For example, go to canada.ca/line-10100 for information about line 10100.
Step 2 – Total income

As a resident of Canada, you need to report your income from all sources inside and outside Canada.
Employment income (box 14 of all T4 slips) 10100 1

Tax-exempt income for emergency services volunteers
(see line 10100 of the guide) 10105
Commissions included on line 10100 (box 42 of all T4 slips) 10120
Wage-loss replacement contributions (see line 10100 of the guide) 10130
Other employment income (see line 10400 of the guide) 10400 2
Old age security (OAS) pension (box 18 of the T4A(OAS) slip) 11300 7,486 71 3
CPP or QPP benefits (box 20 of the T4A(P) slip) 11400 9,463 92 4
Disability benefits included on line 11400
(box 16 of the T4A(P) slip) 11410
Other pensions and superannuation
(see line 11500 of the guide and line 31400 of the return) 11500 19,063 92 5
Elected split-pension amount (complete Form T1032) 11600 6
Universal child care benefit (UCCB) (see the RC62 slip) 11700 7
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UCCB amount designated to a dependant 11701
Employment insurance and other benefits (box 14 of the T4E slip) 11900 8
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A
Employment insurance maternity and parental benefits, and provincial
parental insurance plan benefits 11905
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Taxable amount of dividends from taxable Canadian corporations (use Federal Worksheet):
Amount of dividends (eligible and other than eligible)
A 12000 9
Amount of dividends (other than eligible) 12010
Y
N C
Interest and other investment income (use Federal Worksheet) 12100 10
B
Net partnership income (limited or non-active partners only) 12200 11
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Registered disability savings plan income (box 131 of the T4A slip) 12500 12
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Rental income (see Guide T4036) Gross 12599 Net 12600 13

Taxable capital gains (complete Schedule 3) 12700 14
Support payments received
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(see Guide P102) Total 12799 Taxable amount 12800 15

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Registered retirement savings plan (RRSP) income (from all T4RSP slips) 12900 16
Other income (specify): See attached schedule 13000 500 00 17
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Taxable scholarships, fellowships, bursaries, and artists' project grants 13010 18

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Add lines 1 to 18. 36,514 55 19

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Self-employment income (see Guide T4002):

Business income Gross 13499 Net 13500 20
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Professional income Gross 13699 Net 13700 21

Commission income Gross 13899 Net 13900 22
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Farming income Gross 14099 Net 14100 23

Fishing income Gross 14299 Net 14300 24
Add lines 20 to 24. Net self-employment income 25
Line 19 plus line 25 36,514 55 26
Workers' compensation benefits (box 10 of the T5007 slip) 14400 27
Social assistance payments 14500 28
Net federal supplements paid (box 21 of the T4A(OAS) slip) 14600 29
Add lines 27 to 29 (see line 25000 in Step 4). 14700 30
Line 26 plus line 30 Total income 15000 36,514 55 31
5006-R E (21) Page 3 of 8

Step 3 – Net income
Enter the amount from line 31 of the previous page. 36,514 55 32

Pension adjustment
(box 52 of all T4 slips and box 034 of all T4A slips) 20600
Registered pension plan (RPP) deduction
(box 20 of all T4 slips and box 032 of all T4A slips) 20700 33
RRSP deduction (see Schedule 7 and attach receipts) 20800 34
Pooled registered pension plan
(PRPP) employer contributions
(amount from your PRPP contribution receipts) 20810
Deduction for elected split-pension amount (complete Form T1032) 21000 35
Annual union, professional, or like dues (receipts and box 44 of all T4 slips) 21200 36
Universal child care benefit repayment (box 12 of all RC62 slips) 21300 37
Child care expenses (complete Form T778) 21400 38
Disability supports deduction (complete Form T929) 21500 39
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Business investment loss
(see Guide T4037) Gross 21699 Allowable deduction 21700 40
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Moving expenses (complete Form T1-M) 21900 41
Support payments made
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(see Guide P102) Total 21999 Allowable deduction 22000 42
Carrying charges, interest expenses, and other expenses
A
(use Federal Worksheet) 22100
Y 43
N C
B
Deduction for CPP or QPP contributions on self-employment income and
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other earnings (complete Schedule 8 or Form RC381, whichever applies) 22200 44

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Deduction for CPP or QPP enhanced contributions on employment income

(complete Schedule 8 or Form RC381, whichever applies) (maximum $290.50) 22215 45
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Exploration and development expenses (complete Form T1229) 22400 46

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Other employment expenses (see Guide T4044) 22900 47

Clergy residence deduction (complete Form T1223) 23100 48
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Other deductions (specify): 23200 49

Federal COVID-19 benefits repayment
O
(box 201 of all federal T4A slips) 23210 50

N
Add lines 33 to 50. 23300 51

Line 32 minus line 51 (if negative, enter "0") Net income before adjustments 23400 36,514 55 52
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Social benefits repayment (including old age security benefits repayment, employment insurance
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benefits repayment, and Canada recovery benefit repayment):
See the repayment chart on the back of your T4E slip if you entered an amount on line 11900 and
the amount on line 23400 is more than $70,375.
Use your Federal Worksheet if you entered an amount on line 11300 or line 14600 and the amount
on line 23400 is more than $79,845, or if you have an amount in box 202 of your T4A slip and the
amount on line 23400 is more than $38,000.
Otherwise, enter "0" on line 23500. 23500 53
Line 52 minus line 53 (if negative, enter "0")
(If this amount is negative, you may have a non-capital loss.
See Form T1A.) Net income 23600 36,514 55 54
5006-R E (21) Page 4 of 8

Step 4 – Taxable income

Canadian Armed Forces personnel and police deduction
(box 43 of all T4 slips) 24400 56
Security options deductions
(boxes 39 and 41 of T4 slips or see Form T1212) 24900 57
Other payments deduction (enter the amount from line 14700 if you did
not enter an amount on line 14600; otherwise, use Federal Worksheet) 25000 58
Limited partnership losses of other years 25100 59
Non-capital losses of other years 25200 60
Net capital losses of other years 25300 61
Capital gains deduction (complete Form T657) 25400 62
Northern residents deductions (complete Form T2222) 25500 63
Additional deductions (specify): 25600 64
Add lines 56 to 64. 25700 65
Line 55 minus line 65 (if negative, enter "0") Taxable income 26000 36,514 55 66
Step 5 – Federal tax
Part A – Federal tax on taxable income
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Use the amount from line 26000 to complete the appropriate column below.
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Line 26000 is Line 26000 is more Line 26000 is more Line 26000 is more Line 26000 is more
$49,020 or less than $49,020 but not
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than $98,040 but not than $151,978 but not than $216,511
more than $98,040
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more than $151,978 more than $216,511
N C
Amount from line 26000 36,514 55 67
B
0 00 49,020 00 98,040 00 151,978 00 216,511 00 68
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Line 67 minus line 68

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PL
(cannot be negative) 36,514 55 69

Line 69 multiplied by the 15% 20.5% 26% 29% 33% 70
percentage from line 70 5,477 18 71
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Line 71 plus line 72 0 00 7,353 00 17,402 10 31,425 98 50,140 55 72

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Federal tax on
taxable income 5,477 18 73
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Enter the amount from line 73 on line 116 and continue at line 74.
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Part B – Federal non-refundable tax credits

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Basic personal amount:

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If the amount on line 23600 is $151,978 or less, enter $13,808.

If the amount on line 23600 is $216,511 or more, enter $12,421.
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Otherwise, use the Federal Worksheet to calculate the amount to enter. (maximum $13,808) 30000 13,808 00 74
Age amount (if you were born in 1956 or earlier)
(use Federal Worksheet) (maximum $7,713) 30100 7,713 00 75
Spouse or common-law partner amount (complete Schedule 5) 30300 76
Amount for an eligible dependant (complete Schedule 5) 30400 77
Canada caregiver amount for spouse or common-law partner, or eligible dependant age 18 or older
(complete Schedule 5) 30425 78
Canada caregiver amount for other infirm dependants age 18 or older
Canada caregiver amount for infirm children under 18 years of age (see Schedule 5)
Number of children you are claiming this amount for 30499 x $2,295 = 30500 80
Add lines 74 to 80. 21,521 00 81
5006-R E (21) Page 5 of 8

Part B – Federal non-refundable tax credits (continued)

Base CPP or QPP contributions (complete Schedule 8 or Form RC381, whichever applies):
through employment income 30800 83
on self-employment income and other earnings 31000 84
Employment insurance premiums:
through employment
(boxes 18 and 55 of all T4 slips) (maximum $889.54) 31200 85
on self-employment and other eligible earnings
Volunteer firefighters' amount 31220 87
Search and rescue volunteers' amount 31240 88
Canada employment amount:
Enter whichever is less: $1,257 or line 1 plus line 2. 31260 89
Home buyers' amount (maximum $5,000) 31270 90
Home accessibility expenses
(use Federal Worksheet) (maximum $10,000) 31285 91
Adoption expenses 31300 92
Digital news subscription expenses
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(see line 31350 of the guide) (maximum $500) 31350 93
Add lines 83 to 93. 94
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A
Pension income amount (use Federal Worksheet) (maximum $2,000) 31400 2,000 00 95
Add lines 82, 94, and 95. 23,521 00 96
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Disability amount for self
A
(if you were under 18 years of age, use Federal Worksheet; if not, claim $8,662) 31600 97
Disability amount transferred from a dependant (use Federal Worksheet)
Y 31800 98
N C
Add lines 96 to 98. 23,521 00 99
B
Interest paid on your student loans (see Guide P105) 31900 100
I
Your tuition, education, and textbook amounts (complete Schedule 11) 32300 101
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PL
Tuition amount transferred from a child or grandchild 32400 102

Amounts transferred from your spouse or common-law partner (complete Schedule 2) 32600 103
Add lines 99 to 103. 23,521 00 104
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Medical expenses for self, spouse or common-law partner,

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and your dependent children born in 2004 or later 33099 105

Amount from line 23600 36,514 55 × 3% = 1,095 44 106
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Enter whichever is less: $2,421 or the amount from line 106. 1,095 44 107
Line 105 minus line 107 (if negative, enter "0") 108
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Allowable amount of medical expenses for other dependants

N
(use Federal Worksheet) 33199 109

Line 108 plus line 109 33200 110
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Line 104 plus line 110 33500 23,521 00 111

Federal non-refundable tax credit rate 15% 112
D
Line 111 multiplied by the percentage from line 112 33800 3,528 15 113
Donations and gifts (complete Schedule 9) 34900 314 20 114
Line 113 plus line 114 Total federal non-refundable tax credits 35000 3,842 35 115
5006-R E (21) Page 6 of 8

Part C – Net federal tax
Enter the amount from line 73. 5,477 18 116

Federal tax on split income (complete Form T1206) 40424 117
Line 116 plus line 117 40400 5,477 18 118
Federal dividend tax credit (use Federal Worksheet) 40425 120
Minimum tax carryover (complete Form T691) 40427 121
Add lines 119 to 121. 3,842 35 3,842 35 122
Line 118 minus line 122 (if negative, enter "0") Basic federal tax 42900 1,634 83 123
Federal surtax on income earned outside Canada (complete Form T2203) 124
Line 123 plus line 124 1,634 83 125
Federal foreign tax credit (complete Form T2209) 40500 126
Line 125 minus line 126 1,634 83 127
Recapture of investment tax credit (complete Form T2038(IND)) 128
Line 127 plus line 128 1,634 83 129
Federal logging tax credit (see guide) 130
Line 129 minus line 130 (if negative, enter "0") Federal tax 40600 1,634 83 131
Federal political contribution tax credit (use Federal Worksheet)
Total federal political contributions
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(attach receipts) 40900 (maximum $650) 41000 132
Investment tax credit (complete Form T2038(IND)) 41200 133
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Labour-sponsored funds tax credit (see line 41400 of the guide)
Net cost of shares of a provincially
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registered fund 41300 Allowable credit 41400 134
Add lines 132 to 134.
A 41600 135
Line 131 minus line 135 (if negative, enter "0")
Y 41700 1,634 83 136
N C
Canada workers benefit advance payments received (box 10 of the RC210 slip) 41500 137
B
Special taxes (see line 41800 of the guide) 41800 138
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Add lines 136 to 138. Net federal tax 42000 1,634 83 139
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Step 6 – Refund or balance owing

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CPP contributions payable on self-employment income and other earnings

(complete Schedule 8 or Form RC381, whichever applies) 42100 141
O
Employment insurance premiums payable on self-employment and other eligible earnings

N

Social benefits repayment (amount from line 23500) 42200 143
O
Provincial or territorial tax

(complete and attach your provincial or territorial Form 428, even if the result is "0") 42800 1,161 73 144
D
Add lines 140 to 144. Total payable 43500 2,796 56 145
5006-R E (21) Page 7 of 8

Step 6 – Refund or balance owing (continued)
Total income tax deducted (amounts from all Canadian slips) 43700 4,200 00 147
Refundable Quebec abatement
(see line 44000 of the guide) 44000 148
CPP or QPP overpayment (see line 30800 of the guide) 44800 149
Employment insurance overpayment (see line 45000 of the guide) 45000 150
Refundable medical expense supplement (use Federal Worksheet) 45200 151
Canada workers benefit (CWB) (complete Schedule 6) 45300 152
Canada training credit (CTC) (complete Schedule 11) 45350 153
Refund of investment tax credit (complete Form T2038(IND)) 45400 154
Part XII.2 tax credit
(box 38 of all T3 slips and box 209 of all T5013 slips) 45600 155
Employee and partner GST/HST rebate (complete Form GST370) 45700 156
Eligible educator school supply tax credit
Supplies expenses (maximum $1,000) 46800 x 25% = 46900 157
Canadian journalism labour tax credit (box 236 of all T5013 slips) 47555 158
Other refundable credits (specify): 47556 158a
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Tax paid by instalments 47600 159
Provincial or territorial credits (complete Form 479, if it applies) 47900 160
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A
Add lines 147 to 160. Total credits 48200 4,200 00 4,200 00 161
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If the amount is negative, enter it on line 48400 below.
If the amount is positive, enter it on line 48500 below.
A Refund or balance owing (1,403 44) 162
Y
N C
Generally, the CRA does not charge or refund a difference of $2 or less.
B
Refund 48400 1,403 44 Balance owing 48500
I
D
PL
For more information and ways to enrol for direct deposit, Your balance owing is due no later than April 30, 2022.
go to canada.ca/cra-direct-deposit. For more information on how to make your payment,
go to canada.ca/payments.
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Ontario opportunities fund Amount from line 48400 above 1,403 44 1

You can help reduce Ontario's debt by completing this area to Your donation to the
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donate some or all of your 2021 refund to the Ontario opportunities Ontario opportunities fund 46500 2
fund. Please see the provincial pages for details. 46600 1,403 44 3
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Net refund (line 1 minus line 2)

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I certify that the information given on this return and in any attached If this return was completed by a tax professional, tick the
documents is correct, complete and fully discloses all of my income. applicable box and provide the following information:
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Sign here Was a fee charged? 49000 Yes No

It is a serious offence to make a false return. EFILE number (if applicable): 48900
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Telephone number: 416 259 8765 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 a right of protection, access to and 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 on Info Source at canada.ca/cra-info-source.
Do not use 48600
this area. 48700 48800
Canada Revenue Agency Approval # : RC-21-107

5006-R E (21) Page 8 of 8
T1-2021 Donations and Gifts Schedule 9
Complete this schedule to claim an amount on line 34900 of your return.
Include the eligible amount of all donations that you want to claim this year that you or your spouse or common-law partner made
in 2021 or in any of the previous five years (or the previous 10 years for ecological gifts made after February 10, 2014) that have
not been claimed before.
You may have charitable donations on your T4, T4A, and T5013 slips.
Attach a copy of this schedule to your paper return.
For more information about donations and gifts, including gifts made to a charity in the United States, see Pamphlet P113,
Gifts and Income Tax.
Donations made to registered charities, registered Canadian amateur athletic associations, registered
journalism organizations, and registered Canadian low-cost housing corporations for the aged 1,180 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
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Donations made to the United Nations, its agencies, and certain registered foreign charitable
organizations 33400 4
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A
Add lines 1 to 4. Total eligible amount of charitable donations 1,180 00 5
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Enter your net income from line 23600 of your return. 36,514 55 A x 75% = 27,385 91 6
Gifts of capital property that is depreciable property
A
(from Chart 2 in Pamphlet P113) 33700
Y B
N C
Gifts of capital property
B
(from Chart 1 in Pamphlet P113) 33900 C
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Amount B plus amount C D x 25% = 7

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PL
Line 6 plus line 7 27,385 91 8

Enter whichever is less: amount A or line 8. Total donations limit 27,385 91 9
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Allowable charitable donations:

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Enter whichever is less: amount from line 5 or line 9. 34000 1,180 00 10

Eligible amount of cultural and ecological gifts (see Pamphlet P113) 34200 11
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Line 10 plus line 11 1,180 00 12

Enter whichever is less: amount from line 12 or $200. 200 00 13
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Line 12 minus line 13 980 00 14

N
Total of ecological gifts only, made after February 10, 2014, and before 2016 included
in the amount on line 11 34210 15
O
Line 14 minus line 15 (if negative, enter "0") 980 00 16

D
Enter your taxable income from line 26000 of your return. 36,514 55 17
Income threshold 216,511 00 18
Amount from line 14 980 00 E
Enter whichever is less: amount from line 16 or line 19. F × 33% = 20
Amount E minus amount F 980 00 G × 29% = 284 20 21
Amount from line 13 200 00 H × 15% = 30 00 22
Add lines 20 to 22.
Enter this amount on line 34900 of your return. Donations and Gifts 314 20 23
See the privacy notice on your return.
5000-S9 E (21) Page 1 of 1

T1-2021
Climate Action Incentive Schedule 14
The Government of Canada has announced its intention to deliver the Climate action incentive (CAI) as a quarterly benefit.
If you are eligible, you would automatically receive your CAI payments four times a year, starting in July 2022. To receive
your payments, you have to file a tax return even if you did not receive income in the year. For more information, go
to canada.ca/child-family-benefits.
The CAI consists of a basic amount and a 10% supplement for residents of small and rural communities.
Complete this schedule only if you reside outside a census metropolitan area (CMA) and expect to continue to reside outside
the same CMA on April 1, 2022. To find out if you reside outside a CMA, go to canada.ca/census-metropolitan-areas.
Attach a copy of this schedule to your paper return.
Census metropolitan areas (CMA) by province of residence
Residents of Alberta Residents of Manitoba Residents of Ontario Residents of Saskatchewan
Calgary Winnipeg Barrie, Belleville, Brantford, Saskatoon
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Edmonton Greater Sudbury, Guelph, Regina
Lethbridge Hamilton, Kingston,
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A
Kitchener-Cambridge-
Waterloo, London, Oshawa,
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Ontario part of Ottawa-
A Gatineau, Peterborough,
Y
St. Catharines-Niagara,
N C
Thunder Bay, Toronto,
B
Windsor
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Tick this box if you reside outside a CMA, as determined by Statistics Canada. 60104 1
SE

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O
N
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5000-S14 E (21) Page 1 of 1

Form ON-BEN
Application for the 2022 Ontario Trillium Benefit 2021
and Ontario Senior Homeowners' Protected B when completed
Property Tax Grant
To find out if you are eligible for the Ontario trillium benefit and the Ontario senior homeowners' property tax grant, see the
Ontario Information Guide in your Income tax package.
Complete the application areas and parts that apply to you and attach this form to your return.
To estimate the amount of the Ontario trillium benefit and Ontario senior homeowners' property tax grant you may be entitled to,
use the calculator at canada.ca/child-family-benefits-calculator.
The payments for these benefits will be issued separately from your tax refund.
If you had a spouse or common-law partner on December 31, 2021, only one of you should apply for the Ontario energy and
property tax credit, the Northern Ontario energy credit, and the Ontario senior homeowners' property tax grant for both of you.
If only one of you is 64 years of age or older on December 31, 2021, that spouse or common-law partner has to apply for
these credits and the grant for both of you.
For a description of principal residence for the purposes of the Ontario energy and property tax credit and the Northern
Ontario energy credit, or the Ontario senior homeowners' property tax grant, see the Ontario Information Guide in your Income
tax package.
Ontario trillium benefit (OTB)
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Ontario sales tax credit (OSTC)
You do not need to apply for the OSTC when you file your tax return. The Canada Revenue Agency will tell you if you are
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A
entitled to receive the credit. For families, the OSTC is paid to the person whose return is assessed first.
M
Application for the Ontario energy and property tax credit (OEPTC)
A
You may qualify for the OEPTC if, on December 31, 2021, you resided in Ontario and any of the following conditions applied:
Y
N C
• Rent or property tax for your principal residence was paid by or for you for 2021
B
• You lived in a student residence
I
• You lived in a long-term care home and an amount for accommodation was paid by or for you in 2021
D
PL
• You lived on a reserve and home energy costs were paid by or for you for your principal residence on the reserve for 2021
If you met any of these conditions and are applying for the 2022 OEPTC, tick this box
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and complete Parts A and B of this form. 61020 X

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Application for the Northern Ontario energy credit (NOEC)

D
T
You may qualify for the NOEC if, on December 31, 2021, you resided in Northern Ontario (see the definition in the Ontario
Information Guide in your tax package), and any of the following conditions applied:
O
N
• Rent or property tax for your principal residence in Northern Ontario was paid by or for you for 2021
• You lived in a long-term care home in Northern Ontario and an amount for accommodation was paid by or for you in 2021
O
• You lived on a reserve in Northern Ontario and home energy costs were paid by or for you for your principal residence
on the reserve for 2021
D
If you met any of these conditions and are applying for the 2022 NOEC, tick this box
and complete Parts A and B of this form. 61040
Choice for delayed single OTB payment

By ticking this box, you are choosing to wait until June 2023 to get your 2022 OTB entitlement.
You will get your OTB in one payment at the end of the benefit year (June 2023) instead of
receiving it monthly from July 2022 to June 2023. 61060
5006-TG E (21) Page 1 of 2

ON-BEN
Application for the Ontario senior homeowners' property tax grant (OSHPTG)
You may qualify for the OSHPTG if, on December 31, 2021, both of the following conditions applied:
• You were 64 years of age or older
• You owned and occupied a principal residence in Ontario that you, or someone on your behalf, paid property tax on for 2021
If you met these conditions and are applying for the 2022 OSHPTG, tick this box.
Enter the total amount of property tax paid on line 61120 in Part A and complete Part B of this form. 61070 X
Part A – Amount paid for a principal residence for 2021
If, on December 31, 2021, you and your spouse or common-law partner occupied separate
principal residences for medical reasons and you are choosing to apply individually for
the OEPTC, the NOEC, or the OSHPTG, tick this box and enter your spouse's or
common-law partner's address in Part C of this form. 61080
Enter the total amount of rent paid for your principal residence (including a private long-term care
home) in Ontario for 2021. (Do not include rent paid for a principal residence that was not subject to
property tax. If you lived in a subsidized housing unit, check with your landlord to find out if property
tax was paid for your unit.) 61100
IL
Enter the total amount of property tax paid for your principal residence in Ontario for 2021.
(If your municipality let you defer all or some of your 2021 property tax, enter only the amount of
TE
A
property tax actually paid to the municipality for the year.) 61120 4,124 33
M
If you resided in a designated student residence in Ontario in 2021, tick this box. 61140
A
If you lived on a reserve, enter the total amount of home energy costs (like electricity and heat) paid
for your principal residence in Ontario for 2021.
Y 61210
N C
Enter the total amount paid for your accommodation in a public long-term care home or non-profit
B
long-term care home in Ontario for 2021. 61230
I
D
PL
Part B – Declaration
Complete this part if you are applying for the OEPTC, the NOEC, or the OSHPTG.
SE
Enter the amounts paid for rent, property tax, home energy costs on a reserve, and accommodation in a public long-term
U
care home or non-profit long-term care home in the column "Amount paid for 2021".
I declare the following information about my principal residences in Ontario during 2021:
D
T
O
Check
Number of this box Name of landlord,
N
months if this is municipality, or supplier

Postal resident Amount a long-term payment was made to,
O
Address code in 2021 paid in 2021 care home as applicable

16 Algoma Street M8Y1C3 12 4,124 33 Toronto
D
Part C – Involuntary separation
If, on December 31, 2021, you and your spouse or common-law partner
occupied separate principal residences in Ontario for medical reasons
and you are choosing to apply individually for the OEPTC, the NOEC
or the OSHPTG, enter your spouse's or common-law partner's address:

5006-TG E (21) Page 2 of 2
Form ON428
2021
Ontario Tax Protected B when completed
Part A – Ontario tax on taxable income
Enter your taxable income from line 26000 of your return. 36,514 55 1
Use the amount from line 1 to complete the appropriate column below.
Line 1 is more than Line 1 is more than Line 1 is more than

Line 1 is $45,142 but not $90,287 but not $150,000 but not Line 1 is more
$45,142 or less more than $90,287 more than $150,000 more than $220,000 than $220,000
Line 2 minus line 3 0 00 45,142 00 90,287 00 150,000 00 220,000 00 3
(cannot be negative) 36,514 55 4
Line 4 multiplied by the 5.05% 9.15% 11.16% 12.16% 13.16% 5
percentage from line 5 1,843 98 6
Line 6 plus line 7 0 00 2,279 67 6,410 44 13,074 41 21,586 41 7
Ontario tax on
taxable income 1,843 98 8
IL
Enter the amount from line 8 on line 51 and continue at line 9.
TE
A
Part B – Ontario non-refundable tax credits
M
Internal use 56050
Basic personal amount
A Claim $10,880 58040 10,880 00 9
Age amount (if you were born in 1956 or earlier) (use Worksheet ON428)
Y
N C
(use Worksheet ON428) (maximum $5,312) 58080 5,312 00 10
B
Spouse or common-law partner amount:
I
Base amount 10,162 00 11

D
PL
Your spouse's or common-law partner's net income

from line 23600 of their return 12
Line 11 minus 12 (if negative, enter "0") (maximum $9,238) 58120 13
SE
Amount for an eligible dependant:

U
Base amount 10,162 00 14

Your eligible dependant's net income
D
T
from line 23600 of their return 15

Line 14 minus line 15 (if negative, enter "0") (maximum $9,238) 58160 16
O
Ontario caregiver amount (use Worksheet ON428) 58185 17

N
Add lines 9, 10, 13, 16, and 17. 16,192 00 18

CPP and QPP contributions:
O
Amount from line 30800 of your return 58240 19

D
Employment insurance premiums:

Adoption expenses (maximum $13,156 per child) 58330 23
Line 18 plus line 24 16,192 00 25
5006-C E (21) Page 1 of 4

Form ON428
Part B – Ontario non-refundable tax credits (continued)
Amount from line 25 of the previous page 16,192 00 26

Pension income amount (maximum $1,504) 58360 1,504 00 27
Line 26 plus line 27 17,696 00 28
Disability amount for self
(claim $8,790 or, if you were under 18 years of age, use Worksheet ON428) 58440 29
Disability amount transferred from a dependant
(use Worksheet ON428) 58480 30
Add lines 28 to 30. 17,696 00 31
Interest paid on your student loans (amount from line 31900 of your return) 58520 32
Your unused tuition and education amounts (attach Schedule ON(S11)) 58560 33
Amounts transferred from your spouse or common-law partner (attach Schedule ON(S2)) 58640 34
Add lines 31 to 34. 17,696 00 35
Medical expenses:
Read line 58689 of your Ontario Information Guide. 58689 36
Amount from line 23600 of your return 36,514 55 37
Applicable rate 3% 38
Line 37 multiplied by the percentage from line 38 1,095 44 39
Enter whichever is less: $2,462 or the amount on line 39. 1,095 44 40
IL
Allowable amount of medical expenses for other dependants
TE
A
(use Worksheet ON428) 58729 42
Line 41 plus line 42 58769 43
M
Line 35 plus line 43, plus line 13 of RC269. 58800 17,696 00 44
Ontario non-refundable tax credit rate
A 5.05% 45
Line 44 multiplied by the percentage from line 45
Y 58840 893 65 46
N C
Donations and gifts:
B
Amount from line 13
I
of your federal Schedule 9 200 00 x 5.05% = 10 10 47

D
PL
Amount from line 14

of your federal Schedule 9 980 00 x 11.16% = 109 37 48
Line 47 plus line 48 58969 119 47 119 47 49
SE
Line 46 plus line 49

U
Enter this amount on line 54. Ontario non-refundable tax credits 61500 1,013 12 50
D
T
Part C – Ontario tax

O
N
Ontario tax on taxable income from line 8 1,843 98 51

Ontario tax on split income (complete Form T1206) 61510 52
O
Line 51 plus line 52 1,843 98 53

Ontario non-refundable tax credits from line 50 1,013 12 54
D

Ontario minimum tax carryover:
Enter the result of line 55 minus line 52 830 86 56
Ontario dividend tax credit (use Worksheet ON428) 61520 57
Amount from line 40427
of your return × 33.67% = 59
Enter whichever is less: amount from line 58 or line 59. 61540 60
5006-C E (21) Page 2 of 4

Form ON428
Part C – Ontario tax (continued)
Amount from line 61 of the previous page 830 86 62

Ontario surtax:
Amount from line 62 above 830 86 63
Ontario tax on split income from line 52 64
Complete lines 66 to 68 if the amount on line 65 is more than $4,874.

If the amount is less than $4,874, enter "0" on line 68 and continue on line 69.
(Line 65 830 86 – $4,874) × 20% (if negative, enter "0") = 66

(Line 65 830 86 – $6,237) × 36% (if negative, enter "0") = 67
Line 66 plus line 67 68
Line 62 plus line 68 830 86 69
Ontario dividend tax credit from line 57 70
Ontario additional tax for minimum tax purposes:
If you entered an amount on line 98 of Form T691, use Worksheet ON428 to calculate your
additional tax for minimum tax purposes. 72
IL
Line 71 plus line 72 830 86 73
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A
Ontario tax reduction
M
Enter "0" on line 80 if any of the following applies to you:
• You were not a resident of Canada at the beginning of the year
A
• You were not a resident of Ontario on December 31, 2021
Y
N C
• There is an amount on line 72
B
• The amount on line 73 is "0"
I
• Your return is filed for you by a trustee in bankruptcy

D
PL
• You are not claiming an Ontario tax reduction
If none of the above applies to you, complete lines 74 to 80 to calculate your Ontario tax reduction.
SE
U
X Check this box to claim the tax reduction on your return

D
T
Basic reduction 251 00 74

O
If you had a spouse or common-law partner on December 31, 2021,

N
only the individual with the higher net income can claim the amounts
on lines 75 and 76.
O
Reduction for dependent children born in 2003 or later:

D
Number of dependent children 60969 × $464 = 75

Reduction for dependants with a mental or physical impairment:
Number of dependants 60970 × $464 = 76
Add lines 74 to 76. 251 00 77
Amount from line 77 above 251 00 x 2 = 502 00 78

Amount from line 73 above 830 86 79
(if negative, enter "0") Ontario tax reduction 80
Provincial foreign tax credit (complete Form T2036) 82
5006-C E (21) Page 3 of 4

Form ON428
Part C – Ontario tax (continued)
Amount from line 83 of the previous page 830 86 84

Low-income individuals and families tax (LIFT) credit
(complete Schedule ON428–A) 62140 85
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% = 87
Ontario health premium (complete the chart below) 330 87 89
Line 88 plus line 89
Enter this amount on line 42800 of your return. Ontario tax 1,161 73 90
Ontario health premium
Go to the line on the chart below that corresponds to your taxable income from line 1 to determine your Ontario health premium.
IL
Taxable income Ontario health premium
TE
A
$20,000 or less $0
M
more than $20,000 but
not more than $25,000 - $20,000 =
A x 6% =
Y
N C
B
not more than $36,000 $300
I
D
PL

not more than $38,500 36,514 55 - $36,000 = 514 55 x 6% = 30 87 + $300 = 330 87
SE

U

D
T

not more than $48,600 - $48,000 = x 25% = + $450 =
O
N

O

D
not more than $72,600 - $72,000 = x 25% = + $600 =


not more than $200,600 - $200,000 = x 25% = + $750 =
more than $200,600 $900
Enter the result on line 89 above.
5006-C E (21) Page 4 of 4

Schedule ON428-A
Low-income Individuals and Families 2021
Tax (LIFT) Credit Protected B when completed
To find out if you are eligible for the Low-income individuals and families tax (LIFT) credit, see the Ontario Information Guide
in 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

Applicable rate 5.05% 4
Line 3 multiplied by the percentage from line 4 (maximum $850) 5
Calculating your adjusted net income
Amount from line 23600 of your return 36,514 55 6

Amount of registered disability savings plan (RDSP)
IL
income repayment included on line 23200 of your
return 8
TE
A
Add lines 6 to 8. 36,514 55 36,514 55 9
M
Amount of RDSP income included on line 12500
A
of your return 11
Y
N C
B
I
(if negative, enter "0") Your adjusted net income 36,514 55 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 36,514 55 15

Individual income threshold 30,000 00 16
O
Line 15 minus line 16 (if negative, enter "0") 6,514 55 17

D
Line 17 multiplied by the percentage from line 18 651 46 651 46 19

Enter the amount from line 20 on line 62140 of your Form ON428.
Continue on the next page.
5006-A E (21) Page 1 of 2

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 21
Amount of RDSP income repayment included
on line 23200 of your spouse's or common-law
partner's return 23

Amount of RDSP income included on line 12500
of your spouse's or common-law partner's return 26
Line 24 minus line 27 Your spouse's or common-law
(if negative, enter "0") partner's adjusted net income 28
IL
Amount from line 5 of the previous page (maximum $850) 29
TE
A
Amount from line 13 of the previous page 30
Individual income threshold 31
M
A
Amount from line 30 above
Y 33
N C
Amount from line 28 above 34
B
Line 33 plus line 34 Adjusted family net income 35
I
Family income threshold 36

D
PL
Enter whichever is more: amount from line 32 or line 37. 38

SE

U
Line 38 multiplied by the percentage from line 39 40

D
T
Enter the amount from line 41 on line 62140 of your Form ON428.
O
N

O
D
5006-A E (21) Page 2 of 2

Schedule ON(S12)
Ontario Seniors' Home Safety Tax Credit 2021
Complete this schedule if you had eligible home renovation expenses and you are claiming the Ontario seniors' home safety tax
credit. For more information, see the Ontario Information Guide in your income tax package.
Attach a copy of this schedule to your return. Do not include receipts, but keep them in case we ask to see them later.
Note: Use an additional sheet of paper if you need more space.
Supplier or contractor Amount paid

Date of final GST/HST No. Description (including all
invoice Name (if applicable) applicable taxes)
IL
TE
A
M
* Continue on page 2 if you require more space. Subtotal from page 2
A
Y Total eligible expenses 1
N C
Amount of government assistance received or receivable included in the amount on line 1 2
B
Line 1 minus line 2 (maximum $10,000) 3
I
Amount of Ontario seniors' home safety expenses claimed by other eligible individuals
D
PL
included in the amount on line 3 (see notes below) 4

Line 3 minus line 4
Enter this amount on line 63105 of your Form ON479. Home renovation expenses 5
SE
Notes
U
You and your spouse or common-law partner can share the Ontario seniors' home safety tax credit but the amount that can be
claimed cannot be more than the amount that would be allowed if only one of you were claiming this credit. For exceptions, see
D
T
the Ontario Information Guide.

You can claim this credit as long as another person has not already claimed the same eligible expenses.
O
If you share a principal residence with a group of people, the maximum amount of eligible expenses for that residence that can
N
be claimed by the group is the lesser of $10,000 and the amount of eligible expenses that the group paid or incurred.
O
Involuntary separation
If, on December 31, 2021, you and your spouse or common-law 60890
D
partner occupied separate principal residences for medical

reasons, claim the Ontario seniors' home safety tax credit
individually and enter their address on line 60890.
Address of the property
Were the home renovations made at the address you entered on page 1 of your return? If yes, tick this box.
If not, enter the address of the property where the home

renovations were made.

5006-S12 E (21) Page 1 of 2
Schedule ON(S12)
Continued from page 1.
Supplier or contractor
Date on sales Amount paid
sales slip Name GST/HST No. Description (including all
or contract (if applicable) applicable taxes)
IL
TE
A
M
A
Y
N C
B
I
D
PL
SE
U
D
T
O
N
O
D
Subtotal of eligible expenses (enter on page 1)

5006-S12 E (21) Page 2 of 2
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
from box 37 of your T4E slip.
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 - Boxes 197 to 204: CERB and other benefits for COVID-19
Reimbursements for CERB and other benefits for COVID-19 shown on a T4A slip
Exempt income entered on T4A slips
T4A - Box 018: Lump sum payments
T4A - Box 024: Annuities (non-qualifying)
T4A - Box 123: Revoked Deferred Profit Sharing Plan
IL
T4A - Box 125: Disability benefits from a superannuation or pension plan
T4A - Box 129: Tax deferred cooperative share
TE
A
T4A - Box 130: Apprenticeship incentive or completion grant
T4A - Box 133: Variable pension benefits
M
T4A - Box 109: Periodic payments from an unregistered plan
T4A - Box 134: Tax-Free Savings Account (TFSA) taxable amount
A
Y
T4A - Box 136: Federal Income Support for Parents of Murdered or Missing Children grant (PMMC)
N C
T4A - Box 028: Other income - Other
B
T4A - Box 030: Patronage allocations due to business purchases
I
T4A - Box 040: RESP accumulated income payments

D
PL
T4A - Box 042: RESP educational assistance payments

T4A - Box 117: Loan benefits
T4A - Box 150: Labour Adjustment Benefits Act and Appropriation Acts
SE
T4A - Box 154: Cash award or prize from payer

U
T4A - Box 194: PRPP Payments

T4A - Box 205: One-time payment for older seniors 500 00
D
T
T4A-RCA - Statement of distribution from an RCA

T4 - Box 66: Eligible retiring allowances
O
T4 - Box 67: Non-eligible retiring allowances

N
T3 - Box 22: Lump sum pension benefits

T3 - Box 26: Other income
O
T4A(P) - Box 18: Death benefit

T4A - Box 106: Other income - Death benefits
D
T3 - Box 35: Eligible death benefits +

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 500 00
Page 1 of 3
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
IL
Old age security paid back (Box 20 of T4A(OAS) slip)
Net federal supplements paid back
TE
A
Employment insurance benefits paid back (Box 30 of T4E slip)
Registered disability savings plan (RDSP) income repayment
M
Scholarships paid back
Shareholder's loan amounts paid back
A
Canadian motion picture film and videotape write-offs
Y
N C
RCA deductions under subsection 60(t) and 60(u)
B
Split income (from Form T1206)
I
T4RIF - Box 22: Other deductions

D
PL
T4RSP - Box 28: Other deductions

Depletion allowances (from Form T1229)
Transfers to an RPP, an RRIF or an annuity
SE
Deduction for transfers to a registered disability savings plan (RDSP)

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

T4A - Box 201 Repayment of provincial or territorial COVID-19 benefits
D
T
Tax Exempt income for Canadian Indians from T4A(P) slip

Other:
O
N
Total Other Deductions - to line 23200 of your return

O
* 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.
D
Other Deductions - Line 23210
Federal COVID-19 benefits repayments made in 2022 in respect of benefits received in 2021
Page 2 of 3
OTHER
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
Total Income Tax Deducted - Line 43700
From all information slips 4,200 00

Plus T1032 line P - pension transferee
Subtotal 4,200 00
Less T1032 line P - pensioner
IL
Total 4,200 00
TE
A
M
A
Y
N C
B
I
D
PL
SE
U
D
T
O
N
O
D
Page 3 of 3
PENSION
Pension Income Worksheet
Line 31400 – Pension income amount

Amount from line 11500 of your income tax return 19,063 92 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 = 19,063 92 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, 2021,
or you received the payments because of the death of
your spouse or common-law partner + 8
Add lines 7 and 8 = 19,063 92 A
Eligible split-pension amount transferred to your spouse or common-law partner - 9
IL
Line A minus 9 = 19,063 92 10
Eligible split-pension amount transferred from your spouse or common-law partner + 11
TE
A
Add lines 10 and 11 = 19,063 92 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 15

D
PL
Is your spouse or common-law partner a non-resident at the end of the year? Yes No
Enter the amount from line A of their T1032 form 16
Enter the amount from line O of their T1032 form 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, 2021
and you are 64 years or younger
D
Total amounts from box 16 of all their T4RIF slips + 21

Total amounts from box 19 of all their T5 slips + 23
Total amounts from box 024 of all their T4A slips + 24
Total amounts from box 133, of all their T4A slips + 25
Total amounts from box 16 of all their T4RSP slips + 26
Total of lines 21 to 26 less line 20 = 27
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
I

D
PL
Lot number Was this your principal residence for all the years If YES, are you electing out of the automatic rollover on
SE
Yes No X
U
Year of acquisition
D
T

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
D
Lot number Was this your principal residence for all the years If YES, are you electing our of the automatic rollover on
Yes No X
Year of acquisition
spouse/partner:
Note 1: Don't take into account any increase to the adjusted cost base as a result of the election from 1994.

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

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Canada Revenue Agence du revenu Protected B when completed

Step 1 – Identification and other information

Identification Social insurance

Ontario enter your date of entry:

Your current province or territory of residence if it is different

of Canada in 2021 for income

establishment if you were self-employed in 2021: date of departure:

Your spouse's or common-law partner's information

Their first name Their SIN

Tick this box if they were self-employed in 2021. 1

Do not use this area.

at any time in 2021, was more than CAN$100,000? 26600 1 Yes 2 X No

5006-R E (21) Page 2 of 8

Step 2 – Total income

Employment income (box 14 of all T4 slips) 10100 1

Rental income (see Guide T4036) Gross 12599 Net 12600 13

(see Guide P102) Total 12799 Taxable amount 12800 15

Taxable scholarships, fellowships, bursaries, and artists' project grants 13010 18

Add lines 1 to 18. 36,514 55 19

Self-employment income (see Guide T4002):

Professional income Gross 13699 Net 13700 21

Farming income Gross 14099 Net 14100 23

5006-R E (21) Page 3 of 8

Step 3 – Net income

Enter the amount from line 31 of the previous page. 36,514 55 32

Deduction for elected split-pension amount (complete Form T1032) 21000 35

Disability supports deduction (complete Form T929) 21500 39

other earnings (complete Schedule 8 or Form RC381, whichever applies) 22200 44

Deduction for CPP or QPP enhanced contributions on employment income

Exploration and development expenses (complete Form T1229) 22400 46

Other employment expenses (see Guide T4044) 22900 47

Other deductions (specify): 23200 49

(box 201 of all federal T4A slips) 23210 50

Add lines 33 to 50. 23300 51

benefits repayment, and Canada recovery benefit repayment):

5006-R E (21) Page 4 of 8

Step 4 – Taxable income

Enter the amount from line 54 of the previous page. 36,514 55 55

Step 5 – Federal tax

Part A – Federal tax on taxable income

Line 67 minus line 68

(cannot be negative) 36,514 55 69

Line 71 plus line 72 0 00 7,353 00 17,402 10 31,425 98 50,140 55 72

Part B – Federal non-refundable tax credits

Basic personal amount:

If the amount on line 23600 is $151,978 or less, enter $13,808.

5006-R E (21) Page 5 of 8

Part B – Federal non-refundable tax credits (continued)

Enter the amount from line 81 of the previous page. 21,521 00 82

Tuition amount transferred from a child or grandchild 32400 102

Medical expenses for self, spouse or common-law partner,

and your dependent children born in 2004 or later 33099 105

Allowable amount of medical expenses for other dependants

(use Federal Worksheet) 33199 109

Line 104 plus line 110 33500 23,521 00 111

5006-R E (21) Page 6 of 8

Part C – Net federal tax

Enter the amount from line 73. 5,477 18 116

Step 6 – Refund or balance owing