1N{.} }lli: ?'}lis./omrr slmll be used in Rb(}s witil {{lS- t only!

2-BlRFormNo 19C4

TaxAgent'$ Name
{lf Individuau (Lasl Nafile)

28 Taxpayer Irlumber

L$C
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t#*, fi# P ha 6 oN o d$e#/ lJ fiitfiootrt F I iro r/ El d g.#/ I u b S ttes t B ailding N etn e/$t{98t N afi eJSu btliv isi al/,Vill ago 7-ott:s Province

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L o

L ZIP Cods
M u n i d p a Iilylc I y/D i sti c t Earat

Prefened Contact Type - _

t'i Mobite Number Fax Number [] Er*eit Addre ss @qa,rca)
[] enone Number

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Last Name

Declaration
I declare, under the penalties of perlury thai ihis :lpplr.aliln f::rs been made n gooci farih, verifred by me anC io the besi of my knowledge
and belief
is true and correct, pursuant to the provsrons of rr're Natronal lrlternar Reverrue Code. as amended. arld the reguiatrons issued under
authority thereof

(Signature over Printed Nane)

DOCUMENT,ARY REQUIREMENTS:
--[u, r,,i inOlviouai Anyidentificationissuedbyanarrthorizedgovernmentbody(eg.passport) thatshowsthename.addressandbirthdate
of the applicant
government body
[-ls. for Non-lnoividual - Any official docume nt (e.g. Articles oI lncorporal on Certi{icate of Residencv) issued by an auihorized
(e.g. government agency - tax auth{rntv) ihatsho*s the name of the non- ndividual and the address of its principal office
C Additional Attachments, (if applicable),
mortgage,
l-lOeeO of SalelDeed of Assignrnent/Mortgage Document, whrchevt;r is applicable in case of sale, assignment,
purchase and/or disposal of shares of stocks andlor real estate properties
[--lDeed of Donation for donation of properties or ti"ansfer by graluitous title
Transfer of properties by succession:
l--lOeed of Extraludicial Settlement olthe Estate/Judicial Settlement of Estate
Death certificate ot the dece de't
T-l
J--lCas-htnvoice or Ofilcial Receipt tor brar,d rrew uenicles in caser of claim of winnrrrgs involving personal properlies sublect
to registratton
l--lOeeA of Sale or COR with L'lC. in the case of i: sale of second-hand vehtcle
ICertification from Awarding Corlrpany/Person ir] case of Ciainr of Winnings