ISP 1202 Form – Fill Out, Complete and Submit Online

Service	PROTECTED B (when completed)
Canada	Personal Information Bank HRSDC PPU 146

DEEMED PERSON TO REPRESENT THE DECEASED CLIENT FOR THE PURPOSE OF ISSUING A T4A (OAS), T4A (P) and NR4

(Old Age Security and Canada Pension Plan)

INSTRUCTIONS

Complete this form IF:

-You are responsible for the income tax return of a deceased client and there is no executor; AND

-The deceased client was receiving benefits under the Old Age Security Act or the Canada Pension Plan at the time of death.

A.DECEASED CLIENT

First and Last Name:

Social Insurance Number:

Date of death:

Last address:

The deceased was in receipt of (check one or both):

OAS

CPP

B. PERSON TO REPRESENT DECEASED CLIENT

First and Last Name:

Mailing Address:

Telephone Number: (home) (work)

Nature of relationship to deceased:

STATEMENT AND REQUEST

I am responsible for the income tax return of the deceased client and there is no estate. I request to be recognized as the person to represent the deceased client in order to receive the tax information slips (T4A (OAS), T4A (P) and NR4, etc.).

NOTE: A false or misleading statement may result in an administrative monetary penalty and interest, if any, under the Canada Pension Plan or the Old Age Security Act, or in the prosecution of an offence. Any benefits received or obtained to which there was no entitlement would have to be repaid.

Signature of person to represent deceased client

Date

FOR OFFICE USE ONLY

If approved, the person is recognized as the deemed person to represent the deceased client for the purpose of receiving the deceased client's tax information slips (T4A (OAS), T4A (P) and NR4, etc.).

Approve

Deny Reason:

Authorized Signature

Date

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programs and services for the Government of Canada.

SC ISP-1202 (2013-02-15) E

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