*** Transcriber's Note: Please set your voice synthesizer to read most punctuation. When you encounter the caret sign at the end of a line, please enter the applicable information, if necessary. In print, the T5 slip appears 3 times on the page. The slip will be indicated only once. *** T5 (11) (Front) Canada Revenue Agency STATEMENT OF INVESTMENT INCOME Year ^ Dividends from Canadian corporations Box 24 Actual amount of eligible dividends ^ Box 25 Taxable amount of eligible dividends ^ Box 10 Actual amount of dividends other than eligible dividends ^ Box 11 Taxable amount of dividends other than eligible dividends ^ Federal credit Box 26 Dividend tax credit for eligible dividends ^ Box 12 Dividend tax credit for dividends other than eligible dividends ^ Box 13 Interest from Canadian sources ^ Box 18 Capital gains dividends ^ Box 21 Report Code ^ Box 22 Recipient identification number ^ Box 23 Recipient type ^ Other information (see the back) Box ^ Amount ^ Box ^ Amount ^ Box ^ Amount ^ Recipient's name (last name first) and address ^ Payer's name and address ^ Currency and identification codes Box 27 Foreign currency ^ Box 28 Transit ^ Box 29 Recipient account ^ For information, see the back. If you are using this page for the recipient's copies, keep the bottom slip for your records. For information on how to complete this form, see the back. Detach this part before filing your T5 information return. T5 (11) (Back) HOW TO COMPLETE THIS FORM You can use this form whether you file electronically or on paper. Before completing any T5 slip, see Guide T4015, T5 Guide - Return of Investment Income. You can get a copy by going to www.cra.gc.ca/forms or by calling 1-800-959-2221. For more information about filing electronically, go to www.cra.gc.ca/iref. If you file your T5 slips on paper: - Use one sheet for three different recipients for the copy you are sending to the CRA. Do not separate the slips when you send them with your T5 Summary. - Use a separate sheet for the two copies you are giving to the recipient and the copy you are keeping in your records. Send a copy with the T5 Summary to: Ottawa Technology Centre Canada Revenue Agency POSTAL OFFICE Box 9633, Station T Ottawa ON K1G 6H3 Report these amounts on your income tax and benefit return For information on how to report your income, see your tax guide. Boxes 10, 11, 12 Dividends from Canadian corporations other than eligible dividends - The amount an individual has to report as income is the amount shown in box 11. The dividend tax credit to which an individual is entitled is shown in box 12. For more information, see lines 120 and 425 in your tax guide. Box 13 Interest from Canadian sources - For information on how to report this amount on your return, see line 121 in your tax guide. Box 14 - Other income from Canadian sources Box 15 - Foreign income For information on how to report box 14 or 15 amounts on your return, see line 121 in your tax guide. Box 16 - Foreign tax paid We use this amount to calculate your foreign tax credit. For more information, see line 405 of your tax guide. Box 17 - Royalties from Canadian sources If royalties are from a work or invention of yours, enter the amount on line 104 of your return. Otherwise, enter the amount on line 121 of your return. Box 18 Capital gains dividends - Enter this amount on line 174 of Schedule 3, "Capital Gains (or Losses)." Box 19 Accrued income: Annuities This amount is the earnings part of a general annuity. If you were 65 or older at the end of the year, or if you received the annuity payments because of the death of your spouse or common-law partner, report this amount on line 115 of your return. Otherwise, enter this amount on line 121 of your return. Box 21 Report code - The code in this box indicates that this slip is the original ("O"), an amended ("A"), or a cancelled slip ("C"). Box 22 Recipient identification number - If you are an individual (other than a trust), the number in this box is your social insurance number. In all other cases, the number is your 9 characters business number. Box 23 Recipient type - The code in this box indicates if the amount was paid to an individual ("1"), a joint account ("2"), a corporation ("3"), an association, trust, club, or partnership ("4"), or a government ("5"). Boxes 24-25-26 Eligible dividends from Canadian corporations - The amount an individual has to report as income is the amount shown in box 25. The dividend tax credit to which an individual is entitled is shown in box 26. For more information, see lines 120 and 425 in your tax guide. Box 27 Foreign currency - Leave this area blank if you are reporting amounts in Canadian dollars. For more information, see box 27 in the Guide T4015, T5 Guide - Return of Investment Income. Box 28 Transit - If you are reporting for a financial institution or any similar business, enter the recipient's transit code or branch identification code (up to eight characters) in this area. Box 29 Recipient account - If you can identify the recipient by an account number or policy number, enter the appropriate characters (up to 12) in this area. You may have to pay your taxes by instalments. For more information, go to www.cra.gc.ca/instalments or call 1-800-959-8281. Under the Income Tax Act, you have to give your social insurance number (SIN) on request to any person who prepares an information slip for you. If your SIN is not shown on this slip, please contact the payer and provide it. If you do not have a SIN, you should apply for one at any Service Canada Centre. For more information on "Other Information," consult the section "Other information" in Guide T4015, T5 Guide - Return of Investment Income. Privacy Act, Personal Information Bank number CRA PPU 150 and CRA PPU 005