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Protected B when completed
I certify that the information given on this form is, to my knowledge, correct
and complete, and fully discloses the reporting taxpayer's foreign property and
related information.
If someone other than the taxpayer or the partnership prepared
this form, provide their:
Print name Name
Sign here (It is a serious offence to file a false statement.) Address
Telephone number Date (YYYYMMDD) Postal or ZIP code Telephone number
T1135 E (23)    Privacy Act, personal information bank number CRA PPU 035