Fillable Statement of Foreign Income (Québec)

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Statement of Foreign Income (Québec)

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The Statement of Foreign Income (Québec) form is 4 pages long and contains:

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Country of origin: CANADA
File type: PDF

BROWSE QUéBEC (CANADA) FORMS

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Statement of Foreign Income
Family Allowance
Instructions
The information provided in this form will be used to set
the amount of your Family Allowance payment.
We need to know your family income earned in Québec,
elsewhere in Canada and outside Canada for the following
years:
The year of your arrival in Québec;
The year before your arrival in Québec;
The second year before your arrival in Québec if your date
of arrival was between 1 January and 31 May.
Indicate only the earnings outside Canada that have not been
declared and will not be declared to Revenu Québec. You must
also provide your spouse’s earnings outside Canada, even if
he or she does not live in Canada.
The information about earnings declared to Revenu Québec or
that will be declared to Revenu Québec will be transferred to
us directly by that agency. Do not indicate them on this form.
If you or your spouse was living in another Canadian province
on 31 December of one of the years for which we require
information, you must provide a copy of your Notice of
Assessment from the Canada Revenue Agency for that year.
Do not indicate those earnings on this form.
Access to documents held by public bodies and
the protection of personal information
The personal information collected on this form is needed
to study your application. Failure to provide the requested
information in the mandatory sections may result in
a delay or a refusal to process your application. Only
authorized employees have access to the information and it
is only disclosed to other persons or agencies for verification
in cases provided for by law. It can also be used for research,
assessment, analysis or survey purposes. Pursuant to the Act
respecting Access to documents held by public bodies and
the Protection of personal information, you may consult your
personal information and have it corrected.
For more information
Online
By telephone
Québec region: 418 643-3381
Montréal region: 514 864-3873
Toll-free: 1 800 667-9625
If you would like help in completing this form, please contact us.
LPF-812A (2019-11)
Send us this form and the required documents online at
www.retraitequebec.gouv.qc.ca.
Your application will be processed faster and the postal delay will be eliminated.
If you are unable to use the online service, please return the form and required documents to:
Retraite Québec, case postale 7777, Québec (Québec) G1K 7T4
F
M
year month day
year
month day
area code area code
F
M
Complete the sections on the other side.
Statement of Foreign Income
3. Information about your spouse
Family Allowance
1. Information about you
Please print.
Give your Social Insurance Number
2. Earnings not declared to Revenu Québec
Retraite Québec LPF-812A (2019-11)
Sex Family name Given name Social Insurance Number
Date of birth His or her mother’s family name at birth (last name only)
If your spouse is currently living in Canada, provide the following information:
B
Date of arrival in Québec
year month day
Date of arrival in Canada
year month day
Sex Family name Given name
Date of birth Your mother’s family name at birth (last name only)
Telephone Other Extension
Provide the following dates:
A
Date of arrival in Québec
year month day
Date of arrival in Canada
year month day
Indicate all your earnings outside Canada that have not been declared and will not be declared to Revenu Québec.
If you are required to provide a Notice of Assessment from the Canada Revenue Agency, do not indicate those earnings
on this form.
Indicate the amounts in Canadian dollars.
Enter $ 0, for each year in question, if you do not have any earnings to declare.
Step 1: Indicate your year of arrival in Québec (the year indicated in
A
) and
all your income earned outside Canada between 1 January of that year
and your date of arrival in Québec.
Step 2: Enter the year before your arrival in Québec (the year before the year
indicated in
A
)
and all your income earned outside Canada during
that year.
Year Income earned outside Canada
(in Canadian dollars)
$
Year Income earned outside Canada
(in Canadian dollars)
$
Provide a copy of your Notice of Assessment from the Canada Revenue Agency if, during the year indicated in Step 2,
you lived elsewhere in Canada and were not living in Québec on 31 December of that year.
Go to Step 3 if the date you arrived in Québec was between 1 January and 31 May.
Step 3: Enter the second year before your arrival in Québec (the second year
before the year indicated in
A
) and all your income earned outside
Canada during that year.
Year Income earned outside Canada
(in Canadian dollars)
$
Provide a copy of your Notice of Assessment from the Canada Revenue Agency if, during the year indicated in Step 3,
you lived elsewhere in Canada and were not living in Québec on 31 December of that year.
0210812 LA
4. Your spouse’s earnings not declared to Revenu Québec
5. Declaration
Making a false declaration is an offence and may result in repercussions against you.
By sending this form, I declare that the information provided is complete and accurate.
If you have completed this form for another person, provide your personal information below.
Family name Given name
Completed in the capacity of
Telephone
area code
Other
area code
Extension
Retraite Québec LPF-812A (2019-11)
Indicate all his or her earnings outside Canada that have not been declared and will not be declared to Revenu Québec.
If you are required to provide his or her Notice of Assessment from the Canada Revenue Agency, do not indicate those earnings
on this form.
Indicate the amounts in Canadian dollars.
Enter $ 0, for each year in question, if your spouse does not have any earnings to declare.
Step 1: If your spouse has arrived in Québec, indicate his or her year of arrival
(the year indicated in
B
) and all his or her income earned outside
Canada between 1 January of that year and his or her date of arrival
in Québec.
If your spouse is currently living outside Québec, do not indicate any
amounts in this Step.
Step 2: If your spouse has arrived in Québec, enter the year before his
or her arrival in Québec (the year before the year indicated in
B
)
and all his or her income earned outside Canada during that year.
If your spouse is currently living outside Québec, enter all his or her
income earned outside Canada during the year before your arrival
in Québec (the year before the year indicated in
A
).
Year Income earned outside Canada
(in Canadian dollars)
$
Year Income earned outside Canada
(in Canadian dollars)
$
Provide a copy of his or her Notice of Assessment from the Canada Revenue Agency if, during the year indicated
in Step 2, your spouse lived elsewhere in Canada and was not living in Québec on 31 December of that year.
Go to Step 3 if the date he or she arrived in Québec was between 1 January and 31 May.
Step 3: If your spouse has arrived in Québec, enter the second year before
his or her arrival in Québec (the second year before the year indicated
in
B
)
and all his or her income earned outside Canada during
that year.
If your spouse is currently living outside Québec, enter all his or her
income earned outside Canada during the second year before your
arrival in Québec (the second year before the year indicated in
A
).
Year Income earned outside Canada
(in Canadian dollars)
$
Provide a copy of his or her Notice of Assessment from the Canada Revenue Agency if, during the year indicated
in Step 3, your spouse lived elsewhere in Canada and was not living in Québec on 31 December of that year.
Give your Social Insurance Number
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Statement of Foreign Income (Qubec)

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Completed 23 August 2021

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