Determination Of Residency Status (Leaving Canada) - Canada Revenue Agency (Page 4 of 4) in pdf

Ties in another country

If your spouse (or common-law partner) will not stay in Canada, give:

Social Insurance Number

Spouse's (or common-law partner's) name

Citizenship

Spouse's (or common-law partner's) current address

Spouse's (or common-law partner's) date of departure (day/month/year)

Number of months your spouse (or common-law partner) expects to live outside of Canada

If you have children or dependants not staying in Canada, give their name, age, citizenship, and current address, as well as the name and address of the school they attend and the

grade in which they are enrolled:

If you have children and dependants who will follow you at a later date, give:

Their date of departure (day/month/year)

Number of months they expect to live outside of Canada

If you support individuals, other than through a charitable organization, give the name and current address of these people and financial details of your support:

Describe the dwelling in which you live in the other country. Include details such as address, type, size, and whether you rent or own the dwelling. If you rent the dwelling, give the

length of time you have agreed to be a tenant:

Describe the personal possessions (e.g., clothing, furniture, personal items, pets) you will have in the other country:

If you have a driver's licence issued in a country other than Canada, state for which country it is issued, the expiry date, and whether you will renew it:

h) If you have a foreign passport, give details as to which country it is for and if you will renew it when it expires:

i) If applicable, give the name of the insurer of your medical and hospitalization coverage while living outside Canada and the length of the coverage:

j) List the professional, social, or recreational organizations in which you will be a member in countries other than Canada:

k) Describe the investments you will have in countries other than Canada. Include details of chequing and savings accounts, pension and retirement plans, property, and shares in

companies you will have in these countries. Explain why these investments are kept outside Canada:

l) Give details of other consumer relationships, such as lines of credit and credit cards, you will have in other countries:

m) Give the address for your telephone service in other countries, even if it is not listed, and indicate if it is a personal or business service:

Give the address you use for any personal stationery and business cards in other countries:

o) Give the address for any post office boxes and safety deposit boxes you use in other countries:

p) Give details of your involvement and responsibilities in any partnerships, corporate or business relationships, and endorsement contracts you have in other countries:

q) List the countries, other than Canada, you have visited in this calendar year, the length of time spent in each country, and the reason for visiting these countries. Include the dates of

entry and departure for each country visited:

Certification

We use this form as a starting point to get the facts we need in order to give an opinion on your residency status. Contact us if your situation changes since your residency status could

also change.

(print) certify that the information given on this form is to the best of my knowledge, correct and complete.

Signature

Date

More information

If there is more information that we have not asked for and that you feel will help us determine your residency status, give this information here:

Privacy Act, Personal Information Bank number CRA PPU 005