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Please fill out the form below and attach all necessary documentation and return it to 115-2065 Benvoulin CourtOne form needed per person.Last Name: ________________________________First Name: _________________________Address: _____________________________________________ Postal Code______________Phone Number: ___________________________Birthday: _______ /________ /______ Social Insurance Number: _______________________ Day Month YearHave you moved in the last 12 months? ? Yes ? NoIf YES, what was the date and from where? ___________________________________Marital Status (Circle one): Single Married Common-Law Separated Widowed DivorcedHas your marital status changed in the last 12 months? ? Yes ? No-196850243205FULL LEGAL NAME CURRENT ADDRESS DATE OF BIRTH 00FULL LEGAL NAME CURRENT ADDRESS DATE OF BIRTH 3241675243205DATE OF SEPARATION SIN NET INCOME 00DATE OF SEPARATION SIN NET INCOME If YES, please include the following spousal information: Do you have dependent children? ? Yes ? Noright247015NAME __________________________ BIRTHDAY (Age) ____________ SIN _______________ Income __________NAME __________________________ BIRTHDAY (Age) ____________ SIN _______________ Income __________00NAME __________________________ BIRTHDAY (Age) ____________ SIN _______________ Income __________NAME __________________________ BIRTHDAY (Age) ____________ SIN _______________ Income __________If YES, please include the following information:Are you a Canadian Citizen ? Yes ? No Do you want your Information to be Shared with Elections Canada ? Yes ? No Do have a foreign Pension? ? Yes ? No If YES, where from? _____________________Do you own foreign property? ? Yes ? NoDid you sell a principal residence in this last tax year? ? Yes ? NoDo you have a valid Disability Tax Credit (Valid T2201)? ? Yes ? No33655-79375000-43815024638040005025895304457700227330Seniors Outreach00Seniors Outreach ................
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