Complete the information below concerning the deceased.

Name of deceased : __________________________________________

Deceased's social insurance number : _____ _____ _____

The deceased's date of birth : Year ___ Month ___ Day ___

The deceased's date of death : Year ___ Month ___ Day ___

Deceased's address : __________________________________________

Complete the applicable information below concerning the
surviving spouse or common-law partner.

Name of surviving spouse or common-law partner : _____________________________________

Surviving spouse's or common-law partner's social insurance number : _____ _____ _____

Signature of surviving spouse or common-law partner: ____________________ Date : ____________

Your name : __________________________________________

Your telephone number : _________________

Your address : __________________________________________

Your relationship to the deceased ^{Footnote 1} :__________________________________________

Mail this form to the deceased’s tax centre. You can find the mailing addresses of our tax centres,
at Tax centres.

Personal information is collected under the Income Tax Act to administer tax, benefits, and related programs. It may also be used for any purpose related to the administration or enforcement of the Act such as audit, compliance and the payment of debts owed to the Crown. It may be shared or verified with other federal, provincial/territorial government institutions to the extent authorized by law. Failure to provide this information may result in interest payable, penalties, or other actions. Under the Privacy Act, individuals have the right to access their personal information and request corrections if there are errors or omissions. Refer to Info Source, Personal Information Bank CRA PPU 005.