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CALCULATION OF TAX ON AGREEMENTS TO ACQUIRE SHARES (Section 207.1(5) of the Income Tax Act)
Complete this return for 2002 and later tax years for a taxpayer who agreed to acquire shares of the capital stock of a corporation from someone other than the corporation, at a price different from the fair market value of the shares when they were acquired. The date the agreement to acquire the shares was entered into determines which columns to complete in Area 2, below. For each month, attach a description of the shares that were subject to an agreement at any time in the month (other than an option listed on a designated stock exchange). State how many shares were subject to such an agreement. Tax year refers to the tax year of the person required to file this return.

Area 1 ­ Identification
Tax year:

Name

Telephone number

Address

Account number

Area 2 ­ Calculating the amounts subject to tax
Complete columns B to H based on the date the agreement(s) was entered into. A B Month For agreements For agreements D E before after July 13, 1990, July 14, 1990, but before 1993, Enter the fair Enter the total enter the maximum enter the fair market value of the amount of amount required to market value of the shares at the time dividends paid on pay for the shares. shares at the time of the agreement. the shares. of the agreement. January February March April May June July August September October November December Total of all amounts from columns I, J, M, and N Total Total F Enter the total amount of dividends received from the shares. G Enter the total amount of dividends paid on the shares. H Enter the total amount of dividends received from the shares. C For agreements after 1992 but before April 26, 1995 For agreements after April 25, 1995 I Enter 1% of column B. J Enter 1% of column C. K Enter 1% of column D. L Column E minus column F M Enter the amount from column K or column L, whichever is less. N Column G minus column H

Area 3 ­ Calculating tax payable
Send the completed return, along with any payment owing, to the tax centre or tax services office for the area in which the books and records are maintained for the person required to file this return. Send it no later than 90 days after the end of the tax year. Attach a cheque or money order payable to the Receiver General.
Privacy Act, Personal Information Bank number CRA PPU 015 T2000 E (09)

Area 4 ­ Certification
Total of all amounts from columns I, J, M, and N Minus payments on account Balance owing or refund We neither charge nor refund a difference of $2 or less.
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I, , certify that the information given on this return and in any documents attached to it is, to the best of my knowledge, correct and complete.

Date

Authorized person's signature

Position or title