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C O N F I D E N T I A L

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F13-405A(4) (04-09) PDF

Client: _____________________________________________________

Agent: ___________________________________ Date: ___________

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PRINCIPAL AND SECONDARY RESIDENCE

P R I N C I PA L R E S I D E N C E S E C O N DA RY R E S I D E N C E *
YOU YOUR SPOUSE YOU YOUR SPOUSE
If the property is jointly owned,
indicate each spouse’s ownership value. __________________ _________________ __________________ __________________

Acquisition date __________________ _________________ __________________ __________________

If you are co-owner, indicate ownership %. _______________ % _______________ % _______________ % _______________ %

Acquisition costs $_________________ $ ________________ $_________________ $_________________

Land $_________________ $ ________________ $_________________ $_________________

Building(s) $_________________ $ ________________ $_________________ $_________________

Cost of major renovations $_________________ $ ________________ $_________________ $_________________

Market value $_________________ $ ________________ $_________________ $_________________

Municipal evaluation $_________________ $ ________________ $_________________ $_________________

Mortgage balance $_________________ $ ________________ $_________________ $_________________

Mortgage amortization date _____________ years _____________ years _____________ years _____________ years

Interest rate _______________ % _______________ % _______________ % _______________ %

Loan insured in the event of death? Yes No Yes No Yes No Yes No

Loan insured in the event of disability? Yes No Yes No Yes No Yes No

Loan insured in the event of critical illness? Yes No Yes No Yes No Yes No

In the event of death, do your heirs

plan to keep the property? Yes No Yes No Yes No Yes No

* Residence that you occupy only occasionally, such as a cottage, condo, etc.

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INCOME PROPERTY

P R O P E RT Y 1 P R O P E RT Y 2 P R O P E RT Y 3

Acquisition date ___________________ ___________________ ___________________

If you are co-owner, indicate ownership %. _______

You % _______
Spouse % _______
You % _______
Spouse % _______
You % _______
Spouse %

If the property is co-owned,

is it subject to a sale/purchase agreement? Yes No Yes No Yes No

If so, is the agreement covered

by life insurance? Yes No Yes No Yes No

If so, for what amount? $__________________ $ __________________ $ __________________

Land purchase price $__________________ $ __________________ $ __________________

Building purchase price $__________________ $ __________________ $ __________________

Land’s fair market value $__________________ $ __________________ $ __________________

Building’s fair market value $__________________ $ __________________ $ __________________

Cost of major renovations $__________________ $ __________________ $ __________________

(unclaimed as current expenditures)

Accumulated capital cost allowance

at last tax return $__________________ $ __________________ $ __________________

Mortgage balance $__________________ $ __________________ $ __________________

Loan insured in the event of death? ______________ years _______________ years _______________ years

Mortgage balance ________________ % _________________ % _________________ %

Loan insured in the event of death? Yes No Yes No Yes No

Loan insured in the event of disability? Yes No Yes No Yes No

Loan insured in the event of critical illness? Yes No Yes No Yes No

In the event of death, do your heirs plan

to keep the property(ies)? Yes No Yes No Yes No

Was a tax crystallization performed in 1994? Yes No Yes No Yes No

If so, for what amount? $__________________ $ __________________ $ __________________

Gross rental income $__________________ $ __________________ $ __________________

Net rental income $__________________ $ __________________ $ __________________

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REGISTERED SAVINGS

1 REGISTERED RETIREMENT SAVINGS PLAN (RRSP)

YO U YO U R S P O U S E

Daily interest fund $ __________________________ $ __________________________

Guaranteed investments $ __________________________ $ __________________________

Mutual funds $ __________________________ $ __________________________

Segregated funds $ __________________________ $ __________________________

Locked-in RRSP and/or LIRA $ __________________________ $ __________________________

Other $ __________________________ $ __________________________

2 REGISTERED PENSION PLAN

Defined benefit plan*? Yes No Yes No

Coordinated with the RRQ? Yes No Yes No

Anticipated annuity according to your most

recent employer statement $ __________________________ $ __________________________

Starting at __________________years of age _________________years of age

Defined contribution plan

Current balance* $ __________________________ $ __________________________

Total annual contribution (employer and employee) $ __________________________ $ __________________________

3 DEFERRED PROFIT SHARING PLAN (DPSP)

Current balance $ __________________________ $ __________________________

4 REGISTERED RETIREMENT INCOME FUND (RRIF)

Current balance $ __________________________ $ __________________________

Anticipated withdrawal $ __________________________ $ __________________________

5 LIFE INCOME FUND (LIF)

Current balance $ __________________________ $ __________________________

Planned withdrawal $ __________________________ $ __________________________

How much do you set aside annually

for your retirement? $ __________________________ $ __________________________

In what form? ___________________________ ___________________________

Maximum RRSP deductible $ __________________________ $ __________________________

* Attach last statement

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N O N - R E G I S T E R E D S AV I N G S A N D P E R S O N A L P R O P E R T Y
PROPERTY

NON-REGISTERED SAVINGS
YO U YO U R S P O U S E
If the property is jointly owned,
indicate each spouse’s ownership value.

Bank account $ __________________________ $ __________________________

Savings bonds $ __________________________ $ __________________________

Guaranteed investment certificates $ __________________________ $ __________________________

Treasury bonds $ __________________________ $

Mutual funds1 - Current value $ __________________________ $ __________________________

ACB $ __________________________ $ __________________________

Segregated funds1 - Current value $ __________________________ $ __________________________

ACB $ __________________________ $ __________________________

Common shares1 - Current value $ __________________________ $ __________________________

ACB $ __________________________ $ __________________________

Other financial holdings $ __________________________ $ __________________________

How much do you save annually? $ __________________________ $ __________________________

In what form? $ __________________________ $ __________________________

PERSONAL PROPERTY
YO U YO U R S P O U S E
If the property is jointly owned,
indicate each spouse’s ownership value.

Furniture and accessories $ __________________________ $ __________________________

Automobile $ __________________________ $ __________________________

Automobile $ __________________________ $ __________________________

Trailer $ __________________________ $ __________________________

Boat $ __________________________ $ __________________________

Antiques $ __________________________ $ __________________________

Paintings, engravings, etc. $ __________________________ $ __________________________

Jewellery $ __________________________ $ __________________________

Coin collection $ __________________________ $ __________________________

Stamp collection $ __________________________ $ __________________________

Other (specify) ___________________________ $ __________________________ $ __________________________

________________________________________ $ __________________________ $ __________________________

________________________________________ $ __________________________ $ __________________________

1
Please specify the purchase price.

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ADDITIONAL INFORMATION

F13-405A(4) (04-09) PDF