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Statement of Circumstances — Request to Cancel Interest for Financial Hardship (attached to Form RC4288)
[YOUR FULL NAME]
[YOUR MAILING ADDRESS]
Telephone (daytime): [PHONE] · Email: [EMAIL]
Social insurance number: [SIN]
Canada Revenue Agency
[DESIGNATED OFFICE SHOWN ON THE LAST PAGE OF FORM RC4288 FOR YOUR PLACE OF RESIDENCE]
[DATE]
Re: Taxpayer relief under subsection 220(3.1) of the Income Tax Act — inability to pay / financial hardship — tax years [YEARS]
Dear Sir or Madam,
I ask the Minister to cancel or waive [ALL / PART] of the arrears interest charged on my account for the tax years [YEARS], and the [LATE-FILING / INSTALMENT] penalty for [YEAR], because paying them would cause me financial hardship. Form RC4288 and Form RC376 are enclosed.
1. My account
Item Amount
Tax assessed and still owing (not part of this request) $[TAX]
Penalties $[PENALTIES]
Arrears interest to [DATE OF STATEMENT] $[INTEREST]
Total balance $[TOTAL]
Interest now makes up [PERCENTAGE]% of my balance.
2. What happened
[DESCRIBE IN ORDER, WITH DATES: FOR EXAMPLE, LOSS OF JOB ON …, REDUCED HOURS SINCE …, SEPARATION ON …, ILLNESS FROM … TO …, AND HOW EACH EVENT AFFECTED YOUR INCOME.]
Because of this, I could not pay the balance when it was due. I [HAVE PAID $… SINCE … / HAVE A PAYMENT ARRANGEMENT OF $… A MONTH SINCE … / COULD NOT MAKE ANY PAYMENT].
3. Why I cannot pay the interest
My monthly net income is $[INCOME] and my essential monthly expenses are $[EXPENSES] (details in Form RC376). After housing, food, transportation and medical costs I have $[AMOUNT] left each month. My assets are [DESCRIBE, FOR EXAMPLE NO SAVINGS; CAR VALUED AT $…] and my debts other than this account total $[DEBTS].
If the interest stays, I cannot make a reasonable payment arrangement: at $[MONTHLY PAYMENT] a month, the balance [WOULD NOT GO DOWN / WOULD TAKE … YEARS]. Paying it would make it difficult to cover basic needs such as food, shelter, transportation and medical care for a long period.
4. What I ask
Cancel the arrears interest of $[AMOUNT] charged from [DATE] to [DATE] [AND THE PENALTY OF $… FOR …].
Stop further interest while I pay the tax itself under an arrangement of $[AMOUNT] a month, which I propose.
I confirm that the information in this statement and in Form RC376 is true and complete.
Yours faithfully,
____________________
[YOUR FULL NAME]
Enclosed: Form RC4288; Form RC376; bank and credit card statements for the last 3 months; [MORTGAGE OR LEASE, LOAN AND RECURRING BILL STATEMENTS, INVESTMENT STATEMENTS, PROPERTY ASSESSMENT]; [PROOF OF THE EVENTS: TERMINATION LETTER, MEDICAL NOTE …]
For me
[ ] Only penalties and interest are in the request, not the tax itself
[ ] Tax years ending in the last 10 calendar years only (interest accrued in that period only)
[ ] All statements cover the most recent 3 months
[ ] Sent online (My Account, "Request relief of penalties and interest") or by mail on [DATE]