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T P -1.R-V ( 2012-01) 1 of 2

Request for an Adjustment to an Income Tax Return

Complete this form if you wish to make changes to a personal income tax return that you have already filed. If you are requesting an adjustment to claim a refund, your request must concern an income tax return filed for one of the ten calendar years preceding the year of your request. If you are requesting an adjustment to an income tax return filed for a year prior to 2005 under the simplified tax system, read the information on the next page. Complete a separate form for each taxation year for which you are requesting an adjustment. Send the form and your supporting documents (receipts, information slips, schedules, etc.) separately from any income tax return to Revenu Qubec at one of the following addresses: 3800, rue de Marly, Qubec (Qubec) G1X 4A5 C. P. 3000, succursale Place-Desjardins, Montral (Qubec) H5B 1A4

Erase

To prevent any delays in processing your application, be sure to sign your request in Part 3. If your representative has signed the request, attach a power of attorney (form MR-69-V, Power of Attorney, Authorization to Communicate Information, or Revocation, or a similar document, unless you have already filed it and the document is still valid); provide all supporting documents. If your request for an adjustment concerns a line from your income tax return for which an amount has already been claimed but for which supporting documents were not provided, please provide those documents as well as any documents regarding the adjustment requested; provide clear and detailed explanations in Part 2.

Taxation year
Social insurance number

Identification
Last name Address Name of representative (where applicable) Postal code Form MR-69-V (or similar document) Enclosed Already filed First name

Information about the adjustment

Line number on income tax return Amount shown on return or on most recent notice of assessment Amount of adjustment requested Montant corrig (Do not use this column.)

If the space provided is insufficient, attach another sheet giving the information requested. See Completing your request for an adjustment on the next page.
Title of line

Revised amount

Explanations concerning the adjustment

Certification

I certify that the information provided on this form and in the attached documents is accurate and complete.

Signature of individual or representative

Date

Area code

Telephone

Area code

Telephone (work)

Extension

Print the form

Print information

10RQ ZZ 49488281

TP -1.RV ( 2012-01) 2 of 2

Information
Completing your request for an adjustment In Part 2, enter only the information concerning the line for which you are requesting an adjustment. We will calculate any other amounts in your income tax return that may be affected by your request. Enter in the Revised amount column the amount you would have entered on the line for which you are requesting an adjustment if you had taken into account the amounts covered by your request (and by any prior request for the line concerned) when you filed your income tax return. For example, if you are sending us receipts for medical expenses totalling $3,000 for the 2008 taxation year, you claimed no deduction for medical expenses in your 2008 income tax return and your family income for 2008 was $60,000 enter 0 in the Amount shown on return or on most recent notice of assessment column; enter $1,200 in the Revised amount column, that is, the portion of the medical expenses that exceeded 3% of your family income ($3,000 [3% x $60,000]); enter $1,200 in the Amount of adjustment requested column ($1,200 0); give a breakdown of your calculation in the Explanations concerning the adjustment section. Where your request requires you to calculate a deduction or tax credit, you must first determine the revised amount as explained above.You must then determine the amount of the adjustment requested, which is the difference between the revised amount and the amount in your income tax return for the year concerned or on your most recent notice of assessment for that year.

Adjustment to an income tax return filed under the simplified tax system Until 2004, you could file your income tax return under the simplified tax system or the general tax system. A number of deductions and tax credits could be claimed only under the general tax system. You can request an adjustment to an income tax return filed under the simplified tax system, even if your request concerns deductions or tax credits that can be claimed only under the general tax system. In such a case, we will determine whether it is to your advantage to apply the rules for the general tax system. To request an adjustment, enter in the Amount of adjustment requested and Revised amount columns the amount of the deductions and tax credits to which you are entitled and which you would have claimed if you had filed your income tax return under the general tax system. The table below lists the deductions and tax credits you can claim only under the general tax system for 2003 and 2004. Other deductions and tax credits can be claimed for 2002. Contact us to find out which ones. To claim a refund with respect to your 2002 income tax return, you must request an adjustment before January 1, 2013.

Deductions and tax credits that can be claimed only under the general tax system 2003 and 2004
Deductions Taxable capital gains exemption (enclose form TP-726.7-V) Non-capital losses from other years (enclose a note specifying the year in which you sustained the losses) Net capital losses from other years (enclose form TP-729-V) Deduction for patronage dividends received from a cooperative Deduction for employment income earned outside Canada (enclose your RL-17 slip) Deduction for copyright income Deduction for foreign producers Deduction for foreign experts (or foreign specialists) working for a corporation operating a stock exchange business or a securities clearing-house business Deduction for strategic investments, not including the CIP deduction (enclose Schedule D) Deduction for foreign researchers, for foreign experts, for foreign specialists, for foreign professors, for employees of international organizations, or for employees of a corporation or partnership operating an IFC Tax credits Contributions to the Qubec Pension Plan (QPP) Employment Insurance premiums Contribution to the health services fund Union or professional dues Amount for tuition or examination fees (enclose Schedule M) Amount for interest paid on a student loan (enclose Schedule M) Dividend tax credit Carry-forward of alternative minimum tax (enclose form TP-776.42-V) Net tax adjustment for the portion of a single payment accrued to December 31, 1971, under a pension plan or a deferred profit-sharing plan (enclose Schedule E) Deduction for logging tax Deduction for members of the Canadian Forces or of a Canadian police force who are assigned to a recognized special mission (for 2004 only) Deduction for a member of a partnership operating an IFC Deduction for independent traders of financial derivatives Deduction for a stock option or an option to purchase units in a mutual fund trust Other deductions to which you are entitled, that are indicated in the centre of your RL-1 slip (other than contributions made under a retirement compensation arrangement and contributions made to an RPP for service before 1990) Capital cost allowance with respect to certified Qubec films and the additional deduction for such films (line 287 of the tax return) Additional deduction for Qubec resources (line 287 of the tax return) Deduction for share and security issue expenses that relate to Qubec resources Deduction for shares received in exchange for mining property

PBLA ZZ 80667665

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