Statement of Foreign Income

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					                                                                        Information                0205807        LA


                                             Statement of Foreign Income
                                             Refundable Tax Credit for Child Assistance

  The information provided in this form will be used to set the amount of your child assistance payment. Please return the duly
  completed form to:
                                                  Régie des rentes du Québec
                                                        Case postale 7777
                                                   Québec (Québec) G1K 7T4


Please print                                                        Indicate your social insurance number
  1. Information about your identity
  Sex   Family name                                                                       Given name

       F
              Date of birth                              Your mother’s family name at birth
       M            year            month   day




                        area code                                                      area code
  Telephone                                                                   Other                                       Extension
  If you are currently living in Canada, provide the following information:
                                                  year          month   day                                            year         month   day

  Date of arrival in Québec                                                           Date of arrival in Canada


  2.       Earnings outside Canada

       Indicate the amounts in Canadian dollars.
       Enter 0 $, for each year in question, if you do not have any earnings to declare.

  For each year in question:
            If you lived outside Canada, indicate your income earned outside
                                                                                                        Year       Income earned outside Canada
            Canada that was not declared and will not be declared                                                             (in Canadian dollars)
            to Revenu Québec.
            If you lived elsewhere in Canada at some time during the year
                                                                                                                                                               $
            and were not living in Québec on 31 December of that year, provide
            a copy of your Notice of Assessment from the Canada Revenue
            Agency for that year.                                                                                                                              $
            Do not indicate the earnings outside Canada that were declared
            on your Notice of Assessment from the Canada Revenue                                                                                               $
            Agency.

  3. Information about your spouse
  Sex   Family name                                                           Given name                                      Social insurance number

       F
              Date of birth                              His or her mother’s family name at birth
       M            year            month   day



  If your spouse is currently living in Canada, provide the following information:
                                                  year          month   day                                            year         month   day

  Date of arrival in Québec                                                           Date of arrival in Canada


                                                           Complete the sections on the next page.
Régie des rentes du Québec                                                                                                                            LPF-807A (08-02)
                                                           Indicate your social insurance number

  4.     Your spouse’s earnings outside Canada

       Indicate the amounts in Canadian dollars.
       Enter 0 $, for each year in question, if he or she does not have any earnings to declare.

  For each year in question:
            If your spouse lived outside Canada, indicate his or her income
                                                                                     Year          Income earned outside Canada
            earned outside Canada that was not declared and will not                                     (in Canadian dollars)
            be declared to Revenu Québec.
            If your spouse lived elsewhere in Canada at some time during
                                                                                                                                          $
            the year and was not living in Québec on 31 December of that
            year, provide a copy of his or her Notice of Assessment from
            the Canada Revenue Agency for that year.                                                                                      $
            Do not indicate the earnings outside Canada that were declared
            on his or her Notice of Assessment from the Canada Revenue                                                                    $
            Agency.

  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.
                                                                                                                 year      month        day

  Your signature                                                                                     Date
                                                                                                                 year      month        day

  Your spouse’s signature (if applicable)                                                            Date
  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                                              Other                                         Extension
                                                                                                                 year      month        day

  Signature                                                                                          Date

  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

            By Internet                               By telephone                                    TTY

            www.rrq.gouv.qc.ca/enfants
            www.rrq.gouv.qc.ca/enfants                Québec region: 418 643-3381                     Service for the hearing impaired
                                                      Montréal region: 514 864-3873                   Toll free: 1 800 603-3540
                                                      Toll free: 1 800 667-9625

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Régie des rentes du Québec                                                                                                       LPF-807A (08-02)