Retirement Statement York University Pension Plan Registration Number:

Transcription

1 u.-tuv.11stt t~nivi!!t,slty Retirement Statement York University Pension Plan Registration Number: September 7, 2012 Mr. Nuri T Jazairi 102 Lytton Blvd Toronto ON M4R 1 L4 Dear Mr. Jazairi We are pleased to provide you with the estimated pension options available to you effective December 1, The final figures will be determined upon receipt of your completed forms. The enclosed documents provide the details for the options available to you upon your retirement. What Is Enclosed Retirement Calculation Statement Retirement Option Selection Form Waiver of Joint & Survivor Pension Request for Electronic Funds (CIBC Mellon) Tax withholding forms (TD1 and TD10N) Direct Transfer Request Form (T2151) Locking-in Agreement Post Retirement Benefits Enrolment Form To elect a transfer of your funds: Please complete and return the following forms: Option Selection Form Direct Transfer Request Form (T2151) Locking-in Agreement Post Retirement Benefits Enrolment Form Only originals with required signatures, Including witness signatures, will be accepted. Originals may be mailed, scanned or faxed to us. Please refer to the Questions heading for our contact Information. When electing to transfer out the total value of your entitlemeft\ the amount will be recalculated based upon the most current annualized rate of return. The annualized rate of return as of September 7, 2012 is 7.68% To elect a retirement pension benefit~ Please complete and return the following forms: Option Selection Form Spousal Waiver of Joint and Survivor Pension - You are required to complete this form if you are married and electing a pension option that will provide your spouse with a pension less than 60% at your death Request for Electronic Funds (CIBC Mellon) Tax withholding forms (TD1 and TD10N) Post Retirement Benefit Enrolment Form Only originals with required signatures, Including witness signatures, will be accepted. Originals may be mailed, scanned or faxed to us. Please refer to the Questions heading for our contact Information. Additional documentation required Proof of age. Photocopies of birth, baptismal certificates or passports are acceptable. Proof of spouse's age and Social Insurance Number. Photocopies are acceptable. If the forms are received more than 90 days after the retirement date, your pension will be adjusted to a retirement date of the first of the month following the receipt of the forrr.s. 1 of2 9/7/ :58 AM

2 Nuri T Jazairi Page 2 - Retirement Statement Adjustments to Your Pension When you first retire and elect to receive a monthly pension, the actuarial factors used to calculate your pension assume the Pension Fund will earn 6% annually throughout your retirement. Your retirement pension may be adjusted at the beginning of each calendar year if the moving four-year average fund return is in excess of 6% at that time. In the event the moving four-year average fund return is below 6%, no reduction will be made to your pension; however, this deficit will be tracked and future adjustments (positive or negative) will be applied to the reduced amount. You will receive an increment once the deficit is paid up. Benefits York University provides its retirees with post-retirement benefit coverage that is designed to supplement benefits provided by the Ontario Health Insurance Plan (OHIP). Residents of Ontario are entitled to medical coverage under OHIP provided they maintain residency in the province. If you are age 65 or older and have a valid OHIP card, you will also be entitled for benefrts under the Ontario Drug Benefit Program (008), which pays a portion of the cost of certain prescription drugs for seniors. Please note if you move outside the province, the University's benefits plan will not cover the cost normally paid by OHIP or the 008. Currently the premium cost for the post retirement benefits is $18 per month for single coverage or $34 per month for family coverage. Please complete the Post Retirement Benefrts Program Enrolment Participation f'orrn and return it to us. Please continue to use your York employee number but replace the first digit "1" with the number "9". (Example becomes ) Within 30 days of your retirement you may convert the group life insurance and/or voluntary personal accident insurance (if applicable) to an individual policy. Please contact us if you would like to proceed with converting either policy. The York University Retirees Association is an organization of over 400 retired academic and non-academic employees that provides a range of social programs. Enclosed is a membership application as well as a form, which provides additional information. We require your completed paperwort<, as outlined above, to be received in the Pension and Benefits office by the 20th of the month In order to process your benefit by the 1st of the subsequent month. If your completed paperwort< Is received after the 20th of the month, your benefit will be processed the 1st of the month following. The rate of return will be applied accordingly on transferred balances. Questions If you have any questions or require further clarification, please contact us at extension 27572, by fax at , by at askpb@yorku.ca or by regular mail at 8 The Chimney Stack Road, Toronto ON M3J 1P3. 2of2 9/7/ :58 AM

3 U'lfl'lffcRStT lfluvers!ty Calculation Statement York University Pension Plan Registration Number: September 7, 2012 Mr. Nuri T Jazairi 102 Lytton Blvd Toronto, ON M4R 1L4 You are entitled to a retirement benefit from the York University Pension Plan. We have determined your estimated benefit options based on the Plan terms and the information outlined below. The final figures will be determined upon receipt of your completed forms. Please review this information and if any information in this statement is incorrect, please contact the Pension and Benefits Office. Personal Information Social Insurance Number Employee Number Date of Birth Date of Hire Marital Status August 1, 1941 July 1, 1967 Married Pension Information Date Joined University Pension Plan Normal Retirement Date Termination Date Retirement Date Credited Service in the Pension Plan Pre-1987 Post-1986 Final Average Earnings Spousal Information Spouse's Name Spouse's Date of Birth July 1, 1969 July 1, 2007 November30,2012 December 1, years years $161,777 Janet Jazairi July 15, of5 9/7/ :58 AM

4 Nuri T Jazairi Page 2 -Calculation Statement Money Purchase Account Balances at December 1, 2012 Your Contributions University 'Contributions Total Contributions $725, $732, $1,457, Benefits from York University Pension Plan Money Purchase Component Pension Minimum Guaranteed Benefrt.Additional \bluntary Contribution Pension Special Transferred Contributions Pension Total Monthly Pension $7, $10, $0.00 $0.00 $10, Please review the payment options on the following pages, and advise us of your choice of option as soon as possible. Forms of Payment Normal Form of Pension You have an eligible spouse; the normal form for paying your benefit is one that pays you a pension for your lifetime and a 50% spousal pension upon your death to your eligible spouse. Optional Forms of Pension Instead of the normal form, you may elect an optional form of pension. For each of these options, either a reduction or an increase will be made to your pension to ensure that the optional form remains actuarially equivalent to the normal form. You should note that the Ontario Pension Benefits Act requires that a spousal pension of at least 60% must be paid to your surviving eligible spouse upon your death. If you elect an optional form of pension that pays less than 60% to your surviving spouse, you and your spouse must sign a form waiving the right to the 60% minimum. Life Only Pension This pension is payable monthly for as long as you live. No benefit payments are payable to your beneficiary following you death. Please note this option requires the completion of a Spousal Waiver Form. Life Pension with a Guaranteed Period Amount oliomonthly pension: $11, This pension is payable monthly for as long as you live. If you should die within the guaranteed period (5, 10, 15 years) from the commencement of your pension, your beneficiary or estate will receive the commuted value of the remaining pension payments. Please note this option requires the completion of a Spousal Waiver "Form. 5 Year Guarantee amount of monthly pension: 10 Year Guarantee amount of monthly pension: 15 Year Guarantee amount of monthly pension: $11, $10, $10, NuriT Jazair1 Page 3 -Calculation Statement 50% Joint and Survivor Pension This pension is payable monthly for as long as you live, and upon your death, fifty percent (50%) of the pension which was payable during your lifetime will be continued to your spouse for as long as they live. Please note this option requires the completion of a Spousal Waiver Form. Amount of monthly pension: $10, $5, "-' Joint and Survivor Pension with a Guaranteed Period This pension is payable monthly for as long as you live, and if you should die within the guaranteed period (5, 10, 15 years) from the commencement of your pension, pension payments in the same amount as were payable to you will continue to be paid to your spouse, if surviving, for the balance of the guaranteed period. After the 2of5 9/7/ :58 Al

5 ! expiration of the guarantee period, your spouse, if surviving, will receive fifty percent (50%) of your monthly pension payment. If both you and your spouse should die within the guaranteed period (5, 10, 15 years), your beneficiary or estate will receive the commuted value of the remaining pension payments. Please note this option requires the completion of a Spousal Waiver Form. I 5 Year Guarantee amount of monthly pension: $10, $5, Year Guarantee amount of monthly pension: $10, $5, % Joint and Survivor Pension 15 Year Guarantee amount of monthly pension: $9, $4, This pension is payable monthly for as long as you live, and upon your death, sixty percent (60"k) ofthe pension which was payable during your lifetime will be continued to your spouse for as long as they live. Amount of monthly pension: $10, $6, % Joint and Survivor Pension with a Guaranteed Period This pension is payable monthly for as long as you live, and if you should die within the guaranteed period (5, 10, 15 years) from the commencement of your pension, pension payments in the same amount as were payable to you will continue to be paid to your spouse, if surviving, for the balance of the guaranteed period. After the expiration of the guarantee period, your spouse, if surviving, will receive sixty percent (60%) of your monthly pension payment. If both you and your spouse should die within the guaranteed period (5, 10, 15 years), your beneficiary or estate will receive the commuted value of the remaining pension payments. 5 Year Guarantee amount of monthly pension: $10, $6, Year Guarantee amount of monthly pension: $9, $5, NuriT Jazairi 15 Year Guarantee amount of monthly pension: $9, $5, Page 4 - C8lcUation Statement 75% Joint and Survivor Pension This pension is payable monthly for as long as you live, and upon your death, seventy-five percent (75%) ofthe pension which was payable during your lifetime will be continued to your spouse for as long as they live. Amount of monthly pension: $9, $7, % Joint and Survivor Pension with a Guaranteed Period This pension is payable monthly for as long as you live, and if you should die within the guaranteed period (5, 10, 15 years) from the commencement of your pension, pension payments in the same amount as were payable to you will continue to be paid to your spouse, if surviving, for the balance of the guaranteed period. After the expiration of the guarantee period, your spouse, if surviving, will receive seventy-five percent (75%) of your monthly pension payment. If both you and your spouse should die within the guaranteed period (5, 10, 15 years), your beneficiary or estate will receive the commuted value of the remaining pension payments. 5 Year Guarantee amount of monthly pension: $9, $7, Year Guarantee amount of monthly pension: $9, $7, Year Guarantee amount of monthly pension: $9, of5 917/ :58 AM

6 Monthly pension to <:Ontinue to spouse: $7, % Joint and Survivor Pension This pension is payable monthly for as long as you live, and upon your death, one hundred percent (100%) of the pension which was payable during your lifetime will be continued to your spouse for as long as they live. \ \ Amount of monthly pension: Monthly pension to <:Ontinue to spouse: $9, $9, % Joint and Survivor Pension with a Guaranteed Period This pension is payable monthly for as long as you live, and if you should die within the guaranteed period (5, 10, 15 years) from the commencement of your pension, pension payments in the same amount as were payable to you will continue to be paid to your spouse, if surviving, for the balance of the guaranteed period. After the expiration of the guarantee period, your spouse, if surviving, will receive one hundred percent ( 1 00%) of your monthly pension payment. If both you and your spouse should die within the guaranteed period (5, 10, 15 years), your beneficiary or estate will receive the commuted value of the remaining pension payments. 5 Year Guarantee amount of monthly pension: $9, $9, Year Guarantee amount of monthly pension: $9, $9, Year Guarantee amount of monthly pension: $9, $9,t63.27 NuriT Jazairi Page 5 - calculation Statement Account Balance Transfer, Locked-In You can elect to transfer your account balance, along with the commuted value of your additional minimum guaranteed pension, if applicable, in the amount of $1,457,746.24, to one of the following: Locked-In Retirement kcount (LIRA), Life Income Fund (LIF), Locked-in Retirement Income Fund (LRIF), An insurance company to purchase a deferred or invnediate life annuity. Account Balance Transfer, partially Locked-In You can receive a refund totalling $205, This represents 25% of the value of your pension benefit accrued in respect of Credited Service and required contributions on or after January 1, 1965 and prior to January 1, 1987 and any voluntary contributions with accumulated interest. You may elect this amount: A cash refund, subject to income tax deducted at source, or A transfer to a non-locked-in Registered Retirement Savings Plan In addition, you can elect to transfer the remaining account balance, of $1,252,058.22, to one of the following: Locked-In Retirement kcount (LIRA), Life Income Fund (LIF), Locked-in Retirement Income Fund (LRIF), An insurance company to purchase a deferred or immediate life annuity. Adjustments to Your Pension When you first retire and elect to receive a monthly pension, the actuarial factors used to calculate your pension assume the Pension Fund will earn 6% annually throughout your retirement. Your retirement pension may be adjusted at the beginning of each calendar year if the moving four-year average fund return is in excess of 6% at that time. In the event the moving four-year average fund return is below 6%, no reduction will be made to your pension; however, this deficit will be tracked and future adjustments (positive or negative) will be applied to the reduced amount. You will not receive any further increments until the deficit is paid up. Questions If you have any questions or require further clarification, please contact us at extension 27572, by fax at , by at askpb@yorku.ca or by regular mail at 8 The Chimney Stack Road, Toronto ON M3J 1P3. Return completed forms to: 4 of5 9/7/ :581

7 I York University 8 The Chirmey Stack Road Toronto, ON M3J 1P3 5of5 917/ :58 AM

8 YORK I I.::. th! V f'll-$.1 Tfi tl~fvei($1ty Option Selection Form York University Pension Plan Registration Number: Nuri T Jazairi Please read an infonnation carefully, complete this fonn and return it to the Pension and Benefits Offic:e at Yorl!. Univenity within 90 days of your Retirement Date. If the fonn is not received within the 90-day period, your pension wih be adjusted to a retirement date of the fint of the month following the receipt of the fonns. I elec:t to receive option (place check in the appropriate box): One-time payment transfer El $1,252,058.2.! Plus 25% refund ( El Cash or El RRSP Transfer) $205, One-time payment transfer to Locked-in RRSP mjl $1,457, ife Only l!lj $11, /montb ~ife Only, guaranteed 60 months m $I I,348.45/montb ~ife Only, guaranteed 120 months EJ $10,908.27/montb ~ife Only, guaranteed I 80 months El $10,297.19/montb ~oint & Survivor 50% Pension m $10,280.9llmonth ~oint & Survivor 50% Pension, guaranteed 60 months El $I 0,202.23/montl: ~oint & Survivor 50% Pension, guaranteed 120 months El $10,006.30/montl: ~oint & Survivor 50% Pension, guaranteed 180 months El $9,697.19/montl: ~oint & Survivor 60% Pension El $I 0, /montll ~oint & Survivor 60% Pension, guaranteed 60 months l!!l $I 0,000.22/montll ~oint & Survivor 60% Pension, guaranteed 120 months El $9,843.52/montll oint & Survivor 60% Pension, guaranteed I 80 months El $9,585.49/montll oint & Survivor 75% Pension l!!l $9, /montll oint & Survivor 75% Pension, guaranteed 60 months l!!l $9,7 I I. 77 /month ~oint & Survivor 75% Pension, guaranteed 120 months El $9,609.04/montb ~oint & Survivor 75% Pension, guaranteed 180 months m $9,422.68/montb ~oint & Survivor 100% Pension El $9,276. I 6/montb oint & Survivor I OO"A> Pension, guaranteed 60 months El $9,266.3 llmontb oint & Survivor 100% Pension, guaranteed 120 months m $9,242. I llmontll oint & Survivor 100% Pension, guaranteed 180 months El $9,163.27/montb *Requires com_))ietion of a Spousal Waiver Fonn The option selected above will be paid from retirement date. After receipt of your payment the right to alter this option will be lost. PLEASE COMPLETE DECLARATION ON REVERSE NwiT Ja>airi Declaration P, 2- OpiDt Selectm Form I fully understand that: if I have an eligible spouse, my pension must be payable as a Joint and Survivor pension, unless my spouse and I waive this option by completing the prescribed Spousal Waiver Form; the University and the pension fund hereby rely on the accuracy of my certification of marital status to determine the form and amount of the pension beneflls to which I am entitled; I am responsible for informing the University if I have a former spouse(s) that may be entitled to pension benefits as a resuh of a split of pension assets due to a marriage breakdown. I hereby relieve the University and the pension fund of any liability whatsoever should incorrect payments be made as a resuh of any misrepresentation in this declaration. I confnm that I wish my pension to be paid as indicated on the front of this form. 1 of2 9/7/ :59 AM

9 Date-~~~~--~~-----~ We require your paperwork to be received in the Pension and Benefits office by the 20th of the month in order to process your benefit by the 1st of the subsequent month. If your paperwork is received after tbe 20th of the month, your benefit will be processed the 1st of the month following. The rate of return will be applied accordingly on transferred balances 2of2 9/7/ :59 AM

10 REQUEST FOR ELECTRONIC FUNDS TRANSFER OF PENSION PAYMENTS/JOINT ACCOUNTS PENSIONER REFERENCE NUMBER PENSION PLAN NEW D YORK UNIVERSITY CHANGE D NAME: LAST FIRST INITIAL ADDRESS CITY PROVINCE POSTAL CODE SOCIAL INSURANCE NO. (OPTIONAL) I HEREBY AUTHORIZE AND DIRECT CIBC MELLON GLOBAL SECURITIES SERVICES (CIBC MELLON) TO DEPOSIT OR CAUSE TO BE DEPOSITED ANY AND ALL FUTURE PENSION PAYMENTS AS THEY COME DUE USING ELECTRONIC FUNDS TRANSFER TO MY ACCOUNT AT THE FOLLOWING FINANCIAL INSTITUTION: FINANCIAL INSTITUTION NAME ACCOUNT NO. ACCOUNT TYPE PLEASE PROVIDE A SAMPLE CHEQUE MARKED VOID OR HAVE YOUR FINANCIAL INSTITUTION COMPLETE THE FOLLOWING SECTION: THIS SECTION TO BE COMPLETED BY FINANCIAL INSTITUTION INST. NO. IBRA~CH NO. I ACCOUNT NO. ADDRESS CITY BRANCH VERIFICATION I PROVINCE rostalcode AUTHORIZED BRANCH SIGNATURE DATE I HEREBY AGREE AND ACKNOWLEDGE: ACKNOWLEDGMENT AND AGREEMENT 1. THAT ANY PAYMENTS MADE AFTER MY DEATH, OR PAID IN ERROR WHILE ALIVE, ARE TRUST FUNDS TO BE HELD, IN TRUST, FOR THE BENEFIT OF THE ABOVE-CAPTIONED PENSION PLAN; 2. THAT I MUST NOTIFY MY EMPLOYER OR CIBC MELLON OF ANY CHANGE IN THE ABOVE ACCOUNT INFORMATION; 3. THAT I MAY REVOKE OR MODIFY THESE INSTRUCTIONS IN WRITING AT ANY TIME, TO BE EFFECTIVE UPON RECEIPT OF THE SAME BY CIBC MELLON. CUSTOMER SIGNATURE DATE PLEASE RETURN THIS FORM TO: YORK UNIVERSITY, PENSION & BENEFITS OFFICE SUITE A EAST OFFICE BUILDING,470 0 KEELE ST TORONTO, ON M3J 1P3 TOLL FREE NUMBERS: IN CANADA (ENGLISH) IN CANADA (FRENCH) FROM USA FAX NUMBER 1-SOQ SOQ SOQ BOQ

11 canada Revenue Agency Agence du revenu du Canada 2012 PERSONAL TAX CREDITS RETURN TD1.Your employer or payer will use this form to determine the amount of your tax deductions. Read the back before completing this form. Complete this form based on the best estimate of your circumstances. Last name First name and lnltial{s) Date of birth (YYYY/MMIDD) Employee number Address including postal code For non-residents only- Social Insurance number Country of permanent residence I I I I I I I I - 1. Basic personal amount - Every resident of Canada can claim this amount. If you will have more than one employer or payer at the same time in 2012, see "More than one employer or payer at the same time" on the next page. If you are a non-resident, see "Non-residents" on the next page Child amount- Either parent (but not both), may claim $2,191 for each child born in 1995 or later, that resides with both frarents throughout the year. If the child is infirm, add $2,000 to the claim for that child. Any unused portion can be ~ ransferred to that parent's spouse or common-law partner. If the child does not reside with both parents throughout the year, the parent who is entitled to claim the "Amount for an eligible dependanf' on line 8 may also claim the child amount for that same child. 3. Age amount -If you will be 65 or older on December 31, 2012, and hour net income for the year from all sources will be $33,884 or less, enter $6,720. If your net income for the year will be etween $33,884 and $78,684 and you want to calculate a partial claim, get the TD1-WS, Worksheet for the 2012 Personal Tax Credits Return, and complete the appropriate section. 4. Pension income amount:- If you will receive regular pension payments from a pension plan or fund (excluding Canada~ Pension Plan, Quebec Pension Plan, Old Age Security, or Guaranteed Income Supplement payments), enter $2,000 or,; your estimated annual pension income, whichever is less. " 5. Tuiti~n, education, and textbook amounts (full time and part time) - If you are a student enrolled at a university or 1 ' collele, or an educational institution certified by Human Resources and Skills Development Canada, and you will pay more than 1 00 per institution in tuition fees, complete this section. If you are enrolled full time, or if you have a mental or physica.l disabili~ and are enrolled part time, enter the total of the tuition fees you will pay, plus $400 for each month that you will bet enrolle, plus $65 per month for textbooks. If you are enrolled part time and do not have a mental or physical disability, f enter the total of the tuition fees you will pay, plus $120 for each month that you will be enrolled part time, plus $20 per :. month for textbooks. ~ 6. Disability amount - If you will claim the disability amount on your income tax return by using Form T2201, Disability Tax Credit Certificate, enter $7, Spouse or common-law partner amount - If you are supporting your spouse or common-law partner who lives with you, and whose net income for the year will be less than $10,822 ($12,822 if he or she is infirm) enter the difference between this amount and his or her estimated net income for the year. If your spouse's or common-law partner's net income for the year will be $10,822 or more ($12,822 or more if he or she is infirm), you cannot claim this amount. B. Amount for an eligible dependant - If you do not have a spouse or common-law partner and you support a dependent relative who lives with you, and whose net income for the year will be less than $10,822 ($12,822 if he or she is infirm and you did not claim the child amount for this dependant), enter the difference between this amount and his or her estimated net income. If your eligible dependanfs net income for the year will be $10,822 or more ($12,822 or more if he or she is infirm), you cannot claim this amount. 9. Caregiver amount -If you are taking care of a dependant who lives with you, whose net income for the year will be $15,033 or less, and who is either your or your spouse's or common-law partner's: parent or grandparent (aged 65 or older), enter $4,402 ($6,402 if he or she is infirm) or relative (~ed 18 or older) who is dependent on you because of an infirmi~, enter $6;402. If the depen ant's net income for the year will be between $15,033 and $19, 35 ($15,033 and $21,435 if he or she is infirm) and you want to calculate a partial claim, get the TD1-WS, and complete the appropriate section. 10. Amount for infirm dependants age 18 or older- If you sutport an infirm dependant age 18 or older who is your or your spouse's or common-law partner's relative, who lives in anada, and whose net income for the year will be $6,420 or less, enter $6,402. You cannot claim an amount for a dependant you claimed on line 9. If the dependant's net income for the year will be between $6,420 and $12,822 and you want to calculate a partial claim, get the TD1-WS, and complete the appropriate section. 11. Amounts transferred from your spouse or common-law partner- If your spouse or common-law partner will not use all of his or her age amount, pension income amount, tuition, education and textbook amounts, disability amount or child amount on his or her income tax return, enter the unused amount. 12. Amounts transferred from a dependant- If your dependant will not use all of his or her disability amount on his or her income tax return, enter the unused amount. If your or your spouse's or common-law partner's dependent child or grandchild will not use all of his or her tuition, education, and textbook amounts on his or her income tax return, enter the unused amount. 13. TOTAL CLAIM AMOUNT -Add lines 1 through 12. Your employer or payer will use this amount to determine the amount of your tax deductions: [ I I I Continue on the next page ~ TD1 E (12) (Vous pouvez obtenir ce formulaire en fran~als a ou au ) Canada

12 Completing Form TD1 Complete this form only if: you have a new employer or payer and you will receive salary, wages, commissions, pensions, Employment Insurance benefits, or any other remuneration; you want to change amounts you previously claimed (such as when the number of your eligible dependants has changed); you want to claim the deduction for living in a prescribed zone; or you want to inc~ase the amount of tax deducted at source. Sign and date it and give it to your employer or payer. If you do not complete a TD1 form, your new employer or payer will deduct taxes after allowing the basic personal amount only. More than one employer or payer at the same time D If you have more than one employer or payer at the same time and you have already claimed personal tax credit amounts on another TD1 form for 2012, you cannot claim them again. If your total income from all sources will be more than the personal tax credits you claimed on another TD1 form, check this box, enter "0" on line 13 on the front page and do not complete lines 2 to 12. Total income less than total claim amount D Check this box if your total income for the year from all employers and payers will be Jess than your total claim amount on line 13. Your employer or payer will not deduct tax from your earnings. Non-residents Are you a non-resident of Canada who will include 90% or more of your world income when determining your taxable income earned in Canada in 2012? If you are unsure of your residency status, call the International Tax Services Office at If yes, complete the previous page. D If no, check the box, enter "0" on line 13 and do not complete lines 2 to 12, as you are not entitled to the personal tax credits. Provincial or territorial personal tax credits return If your claim amount on line 13 is more than $10,822, you also have to complete a provincial or territorial personal tax credit return. If you are an employee, use the TD1 form for your province or territory of employment. If you are a pensioner, use the TD1 form for your province or territory of residence. Your employer or payer will use both this federal form and your most recent provincial or territorial TD 1 form to determine the amount of your tax deductions. If you are claiming the basic personal amount only (your claim amount on line 13 is $1 0,822), your employer or payer will deduct provincial or territorial taxes after allowing the provincial or territorial basic personal amount. Note: If you are a Saskatchewan resident supporting children under 18 at any time during 2012, you may be able to claim the child amount on Form TD1 SK, 2012 Saskatchewan Personal Tax Credits Return. Therefore, you may want to complete Form TD1 SK even if you are only claiming the basic personal amount on this form. Deduction for living in a prescribed zone If you live in the Northwest Territories, Nunavut, Yukon, or an,12ther prescribed northern zone for more than six months in a row beginning or ending in 2012, you can claim: $8.25 for each day that you live in the prescribed northern zone; or $16.50 for each day that you live in the prescribed northern zone if, during that time, you live in a dwelling that you maintain, and you are the only person living in that dwelling who is claiming this deduction. Employees living in a prescribed intermediate zone can claim 50% of the total of the above amounts. For more information, get Form T2222, Northern Residents Deductions, and the Publication T4039, Northern Residents Deductions- Places in Prescribed Zones. Is Additional tax to be deducted You may want to have more tax deducted from each payment, especially if you receive other income, including non-employment income such as CPP or QPP benefits, or Old Age Security pension. By doing this, you may not have to pay as much tax when you file your income tax return. To choose this option, state the amount of additional tax you want to have deducted from each payment. To change this deduction later, complete a new Form TD1. Is Reduction in tax deductions You can ask to have less tax deducted if on your income tax return you are eligible for deductions or non-refundable tax credits that are not listed on this form (for example, periodic contributions to a Registered Retirement Savings Plan (RRSP), child care or employment expenses, and charitable donations). To make this request, complete Form T1213, Request to Reduce Tax Deductions at Source for year(s),to get a letter of authority from your tax services office. Give the letter of authority to your employer or payer. You do not need a letter of authority if your employer deducts RRSP contributions from your salary. t Certification , -t I certify that the information given in this return is, to the best of my knowledge, correct and complete. Signature It is a serious offence to make a false return. Date

13 r I t>ontario 2012 ONTARIO PERSONAL TAX CREDITS RETURN TD10N Your employer or payer will use this form to determine the amount of your provincial tax deductions. Read the back before completing this form. Complete this form based on the best estimate of your circumstances. Last name First name and initial(s) Date of birth (YYYY/MMIDO) Employee number Address including postal code For non-residents only- Country of Social insurance number permanent residence I I I I I I I I 1. Basic personal amount- Every person employed in Ontario and every pensioner residing in Ontario can claim this amount. If you will have more than one employer or payer at the same time in 2012, see "Will you have more than one employer or payer at the same time?" on the next page. 9! Age amount -If you will be 65 or older on December 31, 2012, and your net income from all sources will be $34,183, or less, enter $4,592. If your net income for the year will be between $34,183 and $64,797 and you want to calculate a partial claim, get the TO 1 ON-WS, Worksheet for the 2012 Ontario Personal Tax Credits Return, and complete the appropriate section. 3. Pension income amount- If you will receive regular pension payments from a pension plan or fund (excluding Canada Pension Plan, Quebec Pension Plan, Old Age Security, or Guaranteed Income Supplement payments), enter $1,300, or your estimated annual pension income, whichever is less. 4. Tuition and education amounts (full time and part time) - If you are a student enrolled at a university, college, or educational institution certified by Human Resources and Skills Development Canada, and you will pay more than $100 per institution in tuition fees, complete this section. If you are enrolled full time, or if you have a mental or physical disabili~ and are enrolled part time, enter the total of the tuition fees you will pay, plus $506 for each month that you will be enrolled If you are enrolled part time and do not have a mental or physical disability, enter the total of the tuition fees you will pay, : plus $151 for each month that you will be enrolled part time. 5. Disability amount -If you will claim the disability amount on your income tax return by using Form T2201, Disability Tax Credit Certificate, enter $7, Spouse or common-law partner amount - If you are supporting your spouse or common-law partner who lives with you, and whose net income for the year will be $798 or less, enter $7,986. If his or her net income for the year will be between $798 and $8,784 and you want to calculate a partial claim, get the TD1 ON-WS, and complete the appropriate section. I t 7. Amount for an eligible dependant- If you do not have a spouse or common-law partner and you support a depende)jt relative who lives with you, and whose net income for the year will be $798 or less, enter $7,986. If his or her net income fbr the year will be between $798 and $8,784 and you want to calculate a partial claim, get the TD10N-WS, and complete the appropriate section. 8. Caregiver amount- If you are taking care of a dependant who lives with you, whose net income for the year will be $15,165 or less, and who is either your or your spouse's or common-law partner's: parent or grandparent (aged 65 or older); or relative (aged 18 or older) who is dependent on you because of an infirmity, enter $4,433. If the dependant's net income for the year will be between $15,165 and $19,598 and you want to calculate a partial claim, get the TD10N-WS, and complete the appropriate section. 9. Amount for infirm dependants age 18 or older- If you are supporting an infirm dependant aged 18 or older who is your or your spouse's or common-law partner's relative, who lives in Canada, and whose net income for the year will be $6,301 or less, enter $4,433. You cannot claim an amount for a dependant you claimed on line B. If the dependant's net income for the year will be between $6,301 and $10,734 and you want to calculate a partial claim, get the TD10N-WS, and complete the appropriate section. 10. Amounts transferred from your spouse or common-jaw partner- If your spouse or common-law partner will not use all of his or her age amount, pension income amount, tuition and education amounts, or disability amount on his or her income tax return, enter the unused amount. 11. Amounts transferred from a dependant- If your dependant will not use all of his or her disability amount on his or her income tax return, enter the unused amount. If your or your spouse's or common-law partner's dependent child or grandchild will not use all of his or her tuition and education amounts on his or her income tax return, enter the unused amount. 12. TOTAL CLAIM AMOUNT- Add lines 1 through 11. Your employer or payer will use your claim amount to determine the amount of your provincial tax deductions. I I Continue on the next page ~ TD10N E (12) (Vous pouvez obtenir ce formulaire en franyais I) ou au ) Canada

14 Completing Form TD10N Complete this form only if you are an employee working in Ontario or a pensioner residing in Ontario and any of the following apply: you have a new employer or payer and you will receive salary, wages, commissions, pensions, Employment Insurance benefits, or any other remuneration; you want to change amounts you previously claimed (such as when the number of your eligible dependants has changed); you want to increase the amount of tax deducted at source. Sign and date it and give it to your employer or payer. If you do not complete a TD1 ON form, your new employer or payer will deduct taxes after allowing the basic personal amount only. Will you have more than one employer or payer at the same time? If you have more tl)an one employer or payer at the same time and you have already claimed personal tax credit amounts on another Form TD1 ON for 2012, you cannot claim them again. If your total income from all sources will be more than the personal tax credits you claimed on another Form TD 1 ON, enter "0" on line 12 on the front page and do not complete lines 2 to 11. Total income less than total claim amount D Check this box if your total income for the year from all employers and payers will be less than your total claim amount on line 12. Your employer or payer will not deduct tax from your earnings. Additional tax tq be deducted If you wish to have more tax deducted, complete the section called "Additional tax to be deducted" on the federal Form TD1. Reduction in tax deductions You can ask to have less tax deducted if on your income tax return you are eligible for deductions or non-refundable tax credits that are not listed on this form (for example, periodic contributions to a Registered Retirement Savings Plan (RRSP), child care or employment expenses, and charitable donations). To make this request, complete Form T1213, Request to Reduce Tax Deductions at Source for years, to get a letter of authority from your tax services office. Give the letter of authority to your employer or payer. You do not need a letter of authority if your employer deducts RRSP contributions from your salary. Forms and publications To get forms and publications go to or call Certification , I certify that the information given in this return is, to the best of my knowledge, correct and complete. Signature It is a serious offence to make a false return. Date