2011 - Academic Enrichment Fund Worksheet by huanghengdong


									                                                            DEPARTMENT OF SURGERY                              APPENDIX A
                                             ACADEMIC ENRICHMENT FUND FOR 2011

                                      STATEMENT OF PROFESSIONAL EARNINGS
                                                  GEOGRAPHIC FULL-TIME MEMBERS (GFT)

One copy of this statement is to be submitted to the Assistant Chair of the Department
of Surgery under confidential cover by March 15, 2012.


INCOME includes:
¨       Payments from the AHC Insurance Plan, or any other provincial or private insurer
¨       Monies received for medico-legal, Specialist on Call, or other such professional consulting
¨       Hospital, University or other salary income for administrative, academic, income guarantees or other work
        related to or arising from the practice of Surgery or Medicine
¨       Stipends from professional organizations for administrative or other purposes
¨       Stipends from Granting Agencies
¨       Monies received as an invited speaker or visiting professor
¨       Directors’ fees or similar income from biotechnology companies, pharmaceutical companies, or the like

Payments from the AHC Insurance Plan, or any other provincial
or private insurer, and Capital Health Income Guarantees                                             LINE 1

Professional consulting (medico-legal, WCB, etc)                                                     LINE 2

                                                                     SUB TOTAL           $

Specialist on Call

Hospital, University or other salary income (please specify)

Stipends from professional organizations

Stipends received for invited speaker/professor

Directors’ fees

                                                                     TOTAL               $

8% of professional fees for service (LINE 1 plus LINE 2)                                 $

Less: Prepayment Received

                                                                     BALANCE DUE         $

I hereby certify that the information given in this statement is true, correct and complete in every respect and
fully discloses my earned professional income from Clinical Practice as reported to Revenue Canada
Taxation. I further certify that there have been no changes in my statement of professional earnings for my
last reporting period arising out of any reassessment by Revenue Canada Taxation.

                             Signature:                                                      Date:


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