REGISTRATION / INTAKE FORM

Seminar Date (if applicable)

Personal Details: First Name Last Name
Spouse (if applicable)
First Name Last Name

Address
Street Apartment
City/Prov Postal Code
Phone Numbers
Home Work
Cell
E-Mail Preferred time to contact



1. I am a:
Person with a disability
Relative of a person with a disability
     (Please indicate relationship):
Support worker
Other

2. How did you hear about us:
Friend/Family Referral
Organization Referral
Website
Newsletter

3. I am interested in information on the following:
Henson Trust/Wills
ODSP Benefits
Tax Credits
Estate & Financial Planning

4. Do you currently have a will?
Yes
No

Additional Information Regarding Person with a Disability

1. Name of person with a disability:

2. Age of person with disability:

3. Nature of the disability:

4. If the person with the disabilty is 18 years of age or older, is (s)he receiving Ontario Disability Support Program (ODSP) benefits?
    Yes (Indicate: $999/mo. $762/mo
    Other $ ) No Unsure

5. If your child receives the ODSP rooming amount ($730/month),can your child help with shopping and cooking, even if supervision is required?
    Yes No

6. Is the person with the disability currently approved for the Disabilty Tax Credit?
    Yes (If yes, what year was (s)he approved?
    No Unsure

7 . Are you or another relative currently claiming the Caregiver Tax Credit?
    Yes (If yes, what year did the claim start?)
    No Unsure

8 . How would you describe the living arrangements of the person with a disability?
    The person with a disability lives with me (or another relative) full-time.
    The person with a disability lives with me (or another relative) part-time,
    e.g. when ill, on weekends, during the holidays, etc. (describe):
    The person with a disability lives in a supported living environment full-time.
    The person with a disability lives independently full-time.
    Other (describe):

9 : If the person with a disability does not live with a relative, do you or another relative provide to him/her any basic necessities such as food, clothing, or shelter?
    Yes No

If you are interested in applying for the Disability or Caregiver Tax Credits, please complete Part B of this form.


REGISTRATION / INTAKE FORM

Part B: Tax Information

(*To be Filled Out If Proceeding With Application For Tax Credits*)

If your family member is over 18 and you are interested in applying for the Disability or Caregiver Tax Credits, we require some additional information to communicate with the Canada Revenue Agency on your behalf. If you do not have all of the information readily available, you can submit it later at your convenience via e-mail as noted below. You may also fill out the form, print it and send it by fax or mail, etc.


In the form below, the "Applicant" refers to the person with taxable income. An applicant may qualify for the Disability or Caregiver Tax Credit if (s)he is disabled or provides support for a relative with a disability.

Name of Applicant
(i.e. person with taxable income)
First Name
Last Name

Applicant's Relationship to Person With a Disability
Relationship

Applicant's Date of Birth

Information from Applicant's Most Recent Tax Return

(if available)

Total Income Line 150) $
Taxable Income (Line 260) $
Refund (Line 484) $
Balance Owing (Line 485) $
Information from Most Recent Tax Return for Person with a Disability (if available) Net Income (Line 236, or what line 236 would be if he/she filed a return) $

 


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