*** Transcriber's Note: Please set your voice synthesizer to read most punctuation when you encounter the caret sign, please enter the applicable information, if necessary.***

Canada Revenu Agency

T1162A-1 E (10)

Protected B (when completed)

PRE-AUTHORIZED PAYMENT PLAN
(PERSONAL QUARTERLY INSTALMENT PAYMENTS)

You may find it convenient to pay your personal income tax instalments with an automatic bank withdrawal, for either the calculated amount or a fixed amount, that will be withdrawn on the quarterly due dates of March 15, June 15, September 15 and December 15.

There are two plans:

Plan 1 No-calculation amount pre-authorized payment

On the quarterly due dates, the CRA will withdraw from your bank account the calculated amount shown in box 2 of the Instalment Reminder sent to you in February and August. As long as you continue to receive an Instalment Reminder, the payments will be automatically withdrawn from your bank account. This amount may change every 6 months. If you stop receiving Instalment Reminders, you must re-activate your pre-authorized payment plan.

Plan 2 Fixed amount pre-authorized payment plan

If you choose to make instalment payments different from the amount shown on the Instalment Reminder, or if you did not receive a reminder but want to pay by instalments, we will withdraw the amount you choose on the quarterly due dates. You must provide us with an amount for this plan. If your circumstances change and you will owe more or less tax, you will have to contact the CRA to change the amount of the withdrawal. This amount will not change unless you request a modification of the amount.

Please visit the CRA Web site at www.cra.gc.ca and select "My account" to create a pre-authorized debit plan.

To complete the authorization form:

1. You must complete and sign the authorization form below.

2. Select one of the payment plans.

3. Include a personal cheque marked "void". Make sure the bank account you use allows chequing privileges. We can only set-up an arrangement using a chequing or savings account.

4. Return the completed form and the cheque to the following address: Canada Revenue Agency, Postal Office Box 9659 Station T, Ottawa ON K1G 6L7. We will send you a letter confirming the arrangement.

We need to receive your completed Pre-Authorized Payment Plan form up to 30 days before payments begin. If you have a payment due within the next 30 days, please make your payment using the remittance form provided with your instalment package.

The pre-authorized payment plan you choose will remain in effect until you cancel it.

Cut here and return this authorization form to the CRA


T1162-1 E (10) (bottom portion)

*** Transcriber's Note: The bottom part of the original copy can be cut and returned to Canada revenue agency. ***

AUTHORIZATION FOR PRE-AUTHORIZED PAYMENT
(PERSONAL QUARTERLY INSTALMENT PAYMENTS)

Personal information

Family name ^
First name ^

Social Insurance Number ^

Address ^
City^
Province / Territory ^
Postal code ^
Daytime phone number ^

Financial institution information (please attach a cheque marked "VOID")

Financial institution ^

Branch number (5 digits) ^
Institution number (3 digits) ^
Account number (12 digits maximum) ^

Pre-authorized payment plans (check one plan only)
(Insert an "X" to the applicable plan)

Plan 1 ^
02/01/05 Debit my bank account for the amount indicated in box 2 of my Instalment Reminder with the starting date indicated below:(select one date only)

March 15 ^
June 15 ^
September 15 ^
December 15 ^
Year: ^

Plan 2 ^
02/02/05 Debit my bank account for the amount of $^
with the starting date indicated below: (select one date only)

March 15 ^
June 15 ^
September 15 ^
December 15 ^
Year: ^

I authorize the CRA to automatically withdraw funds from my/our bank account (as indicated above) for payment of personal tax instalments.

Name (please print) ^
Signature(s) required ^
Date (Year/Month/Day) ^