NAME OF INSTITUTION: ________________________________

IT IS HEREBY CERTIFIED:

THAT the following examination ___________________________________ was taken by

________________________________ on _______________________;

THAT, out of the total fees paid for the examination, the sum of ____________________ constitutes the amount of eligible fees paid for purposes of paragraph 118.5(1)(d) of the Income Tax Act;

THAT the examination is required to obtain a professional status recognized by federal or provincial statute or to be licensed or certified as a tradesperson where that status, license or certification allows the person to practice the profession or trade in Canada;

THAT no part of the above amount was levied for travel, parking, equipment of enduring value, or any charges other than examination fees and ancillary fees (for example, ancillary fees may include the cost of examination materials used during the examination, such as identification cards and certain prerequisite study materials).

Signature of Authorized Officer: _____________________________