Request to Withdraw Consent
of Electronic T4/T4A
Instructions: You may print the form and complete it by hand (please print clearly), or you may
type in all fields (except the signature and date areas), then print and sign. Some versions of
Acrobat Reader will not allow you to save the form after you enter your information.
Please note:
Please be aware that this form requests personal information that allows us to confirm
your identity. Options for submitting this form are listed at the bottom of the page.
We can only provide copies of those T4/T4A forms produced by Human Resources. Some
T4A forms are also distributed by Western’s Office of the Registrar.
Western employee ID number:
Last four digits of Social Insurance Number:
(N.B. If SIN has changed, you must also submit a Personal Data Form and documentation)
Canada Revenue Agency rules allow employers to deliver tax slips electronically.
Check here to withdraw your consent for electronic delivery of T4/T4As and receive paper
slips by mail. The deadline to withdraw consent for the prior tax year is February 17th.
Signature: Date:
When complete, please do one of the following:
Deliver to Human Resources, Room 4159, Support Services Building
Fax form to 519-661-4104
Scan and email the form to
Mail to: Human Resources - T4s
Western University
Room 4159, Support Services Building
London, Ontario N6A 3K7
Questions? Visit our FAQ.
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