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: ____________

Complete the applicable information below concerning the person entering the information for the deceased.

Your name: __________________________________________

Your telephone number: _________________

Your address: __________________________________________

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

Mail this form to the deceased’s tax centre.

Personal information (including the SIN) is collected to administer or enforce 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 the 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 paying interest or penalties, or in 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 Information about Programs and Information Holdings.