Sample T5 Form

THIS IS A SAMPLE FORM AND WILL NOT SUBMIT ANY INFORMATION

Canada Customs and Revenue Agency

Statement of Investment Income

Recipient's Name and Address:
Recipient's Account Number:
Recipient's Taxpayer Identification Number
Box 10: Dividends from Canadian Sources
Box 11: Taxable amount of Dividends
Box 12: Federal Dividend Tax Credit
Box 13: Interest from Canadian Sources
Box 18: Capital gain dividends
Box 21: Report Code
Box 22: Recipient identification number
Box 23: Recipient type
Other information
Box 14: Other income from Canadian Sources
Box 15: Foreign Income
Box 16: Foreign Taxes
Box 17: Royalties from Canadian Sources
Box 19: Accrued income Annuities
Box 20: Amount eligible for resource allowance deduction
Box 27: Foreign Currency
Box 28: Transit
Box 29: Recipient Account

Boxes 10, 11, 12 - Dividends from Canadian corporations - The amount an individual has to report as income is the amount shown in box 11. The federal 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 - See line 121 in your tax guide for information on how to report this amount in your return.

Box 14 - Other income from Canadian Sources

Box 15 - Foreign income
For box 14 and 15 see line 121 in your tax guide for information on how to report these amounts on your return.

Box 16 - Foreign tax paid
We use this amount to calculate your foreign tax credit. For more information see lines 431 and 433 in 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) in 2003.

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 20 - Amount eligible for resource allowance deduction
This amount is included in the total royalty payments in box 17. You may be able to claim 25% of the amount in box 20 as a resource allowance deduction on line 224 of your return. For more information, contact the General Enquiries section of your tax services office.

Box 21 - Report Code - The code in this box indicates that this slip is the original, or that it is an amended slip ("1").

Box 22 - Recipient identification number - If you are an individual (other than a trust), the number in this box is your SIN. In all other cases, the number is your business number.

Box 23 - Recipient type - The code in this box indicates if the amount was paid to an individual ("1"); joint account ("2"); a corporation ("3"); an association, trust, club, or other ("4"); or government ("5").

You may have to pay your taxes by installments. For more information, contact the General Enquiries section of your tax service office.

Under the Income Tax Act, you have to give your social security number (SIN) on request to anyone who has to prepare 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 through any Human Resources Development Canada (HRDC) office.

Interactive Brokers is providing the Form T5 to you in an electronic format, available by logging in to the IB website at http://www.interactivebrokers.com.
You have consented to receive the Form T5 and other financial and tax statements from IB in electronic form and IB will continue to provide this information electronically for each tax year unless you withdraw this consent. In order to receive financial and tax statements electronically from IB, you must have a personal computer with an internet connection, a valid Internet e-mail address, and software allowing you to view the IB website and to read, send and receive e-mail. Please notify IB immediately in the event of a change in your e-mail address by: (i) using those procedures to change a customer e-mail address that may be available on the IB website at http://www.interactivebrokers.com or (ii) contacting IB Customer Service for further instructions.