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Canada Revenue
Agence du revenu
du Canada
Statement of Deferred Security
Options Benefits
Complete this form to keep track of the security options benefits you have deferred as a result of exercising a security option
after February 27, 2000, and up to and including 4:00 p.m. EST on March 4, 2010, to acquire eligible securities as a result of
your employment. Eligible securities are common shares of a class listed on a designated stock exchange in or outside Canada
and units of mutual fund trusts.
The deferred benefits have to be included in your employment income for the year in which you dispose of the security,
become a non-resident, or die.
You have to file this form with your tax return each year that you have an outstanding balance of deferred security
options benefits,
whether or not you have deferred any security options benefits in the year or disposed of any securities in
the year relating to a security option benefit that was previously deferred.
Opening balance of deferred security options benefits
(from your previous year's notice of assessment or notice of reassessment)  1
Benefits that can no longer be deferred:  
(enter this amount on line 10100 of your return) (see note) 65210  2
Closing balance of deferred security options benefits: line 1 minus line 2 65220 =  3
If the amount on line 3 is more than "0", the Canada Revenue Agency will show it on your notice of assessment.  
To claim your "security options deduction" on this amount, enter 50% of line 2 on line 24900 of your return.
You may be able to claim a deduction for donating securities you acquired through your employer's security options plan.
For more information, see "Gifts of securities acquired under a security option plan" in Guide P113, Gifts and Income Tax.
See the privacy notice on your return.
T1212 E (23) (Ce formulaire est disponible en français.)