Employer's name - Nom de l'employeur Canada Revenue Agence du revenu du Canada T4 Neat as a Pin Year Annee 2019 Statement of Remuneration Paid Etat de la remuneration payco imployment income - line 10100 Income tax deducted - line 43700 Revenus d'emploi - ligne 10100 mot sur le reveru retenu - Igne 43700 14 48,200.00 22 Protected B when completed / Protege B une fois rempli 54 Employer's account number / Numero on compto do femployour Province of employ Province d'emploi Employee's CPP cortric Colisations de Temploys au El insuretile ca Social Insurance number Exempt - Exemptic 10 YP 16 2,279.70 24 48,200 00 CPPOPP EI CPP/OPP 12 805 127 115 28 PCRRO AE RPAP 26 48,200.00 Employee's name and ad dom et adresse de l'employ Employee's El premiums Codisations de Temploys & TAE is - line 31200 bone 31200 Colsations syndicales - Igne 21200 780.84 Dox Keith 20102 gne 20700 Charitable donations - line 34900 ons de bien lais ance - ligne 34 900 20 554.00 46 18 Page Place Pension ed RPP or DPSPre ration number oudun RPDB Your City, YP 52 1,108,00 50 3559573 L3A 2N7 mployeo's PPIP p sations de Tempi PPP insuratie e Gains as surables 56 Box - Cosa Amcurt - Montert OK - Coon Amount - Mortont Box - Cone Amourt - Mortont Other information (see over) T4 (19) Autres box - Case Amcurt- Mortart Amount - Mortart Amount - Mortars renseignements (voir au verso) Box 22: BC: 6,893; AB: 7,515; SK: 8,041; MB: 9,056; ON: 7,335; NB: 8,623; NS: 9,211; PE: 9,122; NL: 8,707; YT: 7,003; NT: 6,118; NU: 5,344; Canada Revenue Agence du revenu du Canada Year 2019 Statement of Trust Income Allocations and Designations Annee Etat des revenus de fiducia (repartitions et attributions) T3 Actual amount of eligible dividend Taxable amount of eligible dividends Dividend tax credit for eligible dividends Montant reel des dividendes Montant imposable des dividendes Creat dimpot pour di Capital gains determines Gains en capital Capital gains eligible for deduction determines Gains en capital admissibles pour determines deduction 49 96,00 132.48 19.90 21 182.00 30 Actual amount of dividends other than eligible dividends Taxable amount of dividends s ofer than Dividend tax credit for dividends off des dividendes autres que des eligtie dudencs Montart inpooable des dividendes thin e gale didoends dividendes daforminds Impl pour dividendes aut dividendes determines Other income Trust year end completed / Protege B une fois rempli des dividendes determ Autres revonus Fin dennbe de la fiducia Annee 19 Month 12 Other information Box / Case Amount / Mort ant Box / Cas Amount /Montan Footnotes - Notes (see the back) Autres enseignements (isez leverso) cipient's name (last name first) and actress - Nom, prenom of adresse du beneficiais Trust's name and address - Nom of adresse de la fiducia Dox Keith Thomas Jefferson Dox Trust Protected B when 18 Page Place Your City, YP, L3A 2N7 Recipient identification num Numero didentification du beneficiaire Account number Numero de comple Report code Code du genre de fouillet Beneficiary code Code du beneficiaire For information, see the back. T3 (19) 12 805 127 115 T 48 - 9653 - 33 18 1 Pour obtenir des renseignements, lisez le verso