Sample Source Deduction Letter Revenue Canada Taxation District Taxation Office 
Attn.: Source deductions regarding tax deduction waivers REQUEST FOR REDUCTION 
OF TAX DEDUCTIONS AT SOURCE Name____________________________ SIN____________________ 
Address__________________________________________________________________ Phone 
no. (business)______________________________ Employer's name___________________________________ 
Name of payroll officer __________________________ Address__________________________________________________________________ 
Phone no. (business)______________________________ Address of payroll office, 
if different from above _________________________________________________________________________ 
1 hereby request an authorization for my employer to take into consideration an 
additional exemption for source deduction purposes because 1 anticipate the following 
allowable deduction(s) for the year 19 1. Registered Retirement Savings Plan Premiums: 
$_________________ Attach photocopy of receipts for contributions already made 
or supply details of contributions to be made on a regular purchase plan. 2. Interest 
and Carrying Charges on Investment Loans: $_______________ Attach copy of loan 
agreement with lender, or supply statement(s) from lender(s), confirming amount 
(s) and date (s) of loan (s) and estimated interest for the taxation year State 
purpose of the loan and details of investment of principal amount of loan. For 
mutual fund investment, attach copy of receipts. 3. Alimony or Separation Allowance 
Payment Deemed to Be Child Support Payments to: Name_______________________________________ 
SIN__________________________ Address___________________________________________________ 
$_____________ Attach copy of judgment or written separation agreement (including 
any previous agreement) if not previously filed with the department. Judgment 
or written agreement must have been made before May 1, 1997 for these payments 
to be deductible and payments must not be identified as solely for the support 
of the former spouse. 4. Other: $_______________ Specify and provide full details 
on separate sheets if necessary (e.g., child care expenses, limited partnership 
losses, mining, or other tax shelter investments). STATEMENT OF ESTIMATED INCOME 
FROM ALL SOURCES IN 19 Salary, bonuses, etc. $__________ Commission income less 
expenses claimed on TDIX (Attach copy.) $__________ Interest and foreign dividends	
$__________ Dividends from Canadian taxable corporations(State actual amount.)$__________ 
Net rental income (loss) $__________ Other income (Specify business, capital gains, 
pension, etc.) $__________ Are tax returns filed for all years now due? __________________ 
if not, state years for which returns have not been filed ___________________ 
Explain why tax returns not filed ___________________________________________ 
_____________________________________________________________________________ 
Has assessment notice been received for the latest year required to be filed? 
_____________________________________________________________________________ 
If not, state date return filed _____________________________________________ 
Were any taxes unpaid on filing? ____________________________________________ 
If yes, state amount of debit _______________________________________________ 
if refund claimed, state approximate amount of refund claimed $__________ I claim 
personal tax credits for 19____ for dependents. Spouse (common-law spouse, or 
equivalent to married)_________________________ I certify that the information 
given in this statement is correct and complete to the best of my knowledge and 
belief. Date_______________ Signature____________________________________________