*** 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. *** 
 
Canada Revenue Agency 
 
RETURN OF INVESTMENT INCOME 
 
T5 Summary (11) (Front) 
 
See information on the back. Complete this form using the instructions in the 
Guide T4015, T5 Guide - Return of Investment Income. 
 
Do not use this area 
 
Information return for the year ended December 31, (Year) ^
 
Account number (enter 15 digit) ^
 
If this is an additional T5 Summary, enter "X" here. ^
 
Name of filer or nominee, and address of branch or office filing this form. 
 
Name ^
Address ^
City ^
Province/Territory ^
Postal code ^
 
Have you filed a T5 information return before? Yes or No. ^
 
Indicate your language of choice for correspondence 
Indiquez dans quelle langue vous désirez recevoir votre correspondance 
English or Français ^
 
T5 slip totals 
 
Do not include amounts for which a T5 slip has not been issued. 
 
Box 10 Actual amount of dividends other than eligible dividends ^
Box 11 Taxable amount of dividends other than eligible dividends ^
Box 12 Dividend tax credit for dividends other than eligible dividends ^
Box 13 Interest from Canadian sources ^
Box 14 Other income from Canadian sources ^
Box 15 Foreign income ^
Box 16 Foreign tax paid ^
Box 17 Royalties from Canadian sources ^
Box 18 Capital gains dividends ^
Box 19 Accrued income: Annuities ^
Box 20 Amount eligible for resource allowance deduction ^
 
Box 24 Actual amount of eligible dividends ^
Box 25 Taxable amount of eligible dividends ^
Box 26 Dividend tax credit for eligible dividends ^
 
Box 32 Unclaimed amounts - Dividends and interest ^
Box 33 Tax deducted from unclaimed amounts ^
Box 31 Total number of T5 slips filed ^
 
Do not use this area 
Box 50 ^
Box 51 ^
 
Person to contact about this information return 
Box 41 Name ^
Box 42 Telephone number (including area code) ^
 
Certification 
 
I certify that the information given on this T5 Summary form and related T5 
slips is, to the best of my knowledge, correct and complete. 
 
Authorized person's signature ^
Position or office ^
Date (Year/Month/Day) ^
 
 
T5 Summary (11) (Back) 
 
If you file your T5 information return electronically, do not complete this 
summary. 
 
Mandatory electronic filing 
 
If you file more than 50 T5 slips for a calendar year, you must file the T5 
return over the Internet. 
 
You may choose one of the following electronic filing formats: 
 
1) Internet File Transfer (XML) 
2) Web Forms 
 
For more information about filing electronically, go to www.cra.gc.ca/iref. 
 
You can also file information returns online without a Web access code using 
the "File a return" service at: 
 
- www.cra.gc.ca/representatives, if you are an authorized employee or 
representative; or 
 
- www.cra.gc.ca/mybusinessaccount, if you are the business owner. 
 
Filing electronically 
 
When filing using Web Forms or Internet File Transfer (XML), the information 
is automatically encrypted before it is submitted to the Canada Revenue 
Agency. 
 
For more information about filing electronically, go to www.cra.gc.ca/iref. 
 
Filing on paper 
 
Complete this form using the instructions in Guide T4015, T5 Guide - Return 
of Investment Income. 
 
If you make certain payments to a non-resident of Canada, the amounts should 
be reported on an NR4 return. For more information, see T4061, NR4 - Non-
Resident Tax Withholding, Remitting, and Reporting. 
 
To get forms and publications, go to www.cra.gc.ca/forms or call 1-800-959-
2221. 
 
Send this T5 Summary and the related T5 slips to: 
 
Ottawa Technology Centre 
Canada Revenue Agency 
POSTAL OFFICE Box 9633, Station T 
Ottawa ON K1G 6H3 
 
Privacy Act, Personal Information Bank number CRA PPU 150