Statement of Foreign Income
Child assistance
Instructions
The information provided in this form will be used to set
the amount of your child assistance 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 this information
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.
The Act respecting Access to documents held by public
bodies and the Protection of personal information allows you
to 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.
Please return the completed form to:
Retraite Québec
Case postale 7777
Québec (Québec) G1K 7T4
LPF-812A (16-01)
0210812
LA
Statement of Foreign Income
Child assistance
Indicate your social insurance number
Please print
1. Information about you
Sex Family name
F
M
Date of birth
year
month
day
Given name
Your mother’s family name at birth (last name only)
area code
area code
Telephone OtherExtension
Provide the following dates:
year
month
day
A Date of arrival in Québec
year
month
day
Date of arrival in Canada
2. Earnings not declared to Revenu Québec
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.
Year
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)
$
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.
3. Information about your spouse
Sex
Family name
F
M
Date of birth
year
month
day
Given name
Social insurance number
His or her mother’s family name at birth (last name only)
If your spouse is currently living in Canada, provide the following information:
year
B Date of arrival in Québec
month
day
year
month
day
Date of arrival in Canada
Complete the sections on the other side.
Retraite Québec
LPF-812A (16-01)
4. Your spouse’s earnings not declared to Revenu Québec
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.
Year
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)
$
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.
5. Declaration and signatures
Making a false declaration is an offence and may result in repercussions against you.
Each person who has declared income on this form must sign the form, except a spouse who is still living outside Canada.
I declare that all the information given in this application is true and complete.
Your signature
Date
Your spouse’s signature (if applicable)
Date
year
month
day
year
month
day
year
month
day
If your spouse is living in Canada and you are unable to obtain his or her signature, indicate the reason:
If this form has been completed by another person, that person must provide the following information:
Family name
Given name
Signed in the capacity of
area code
area code
Telephone OtherExtension
Signature
Retraite Québec
Print
Date
LPF-812A (16-01)