| Employer Name: |
(optional) |
| Employee Name: |
(optional) |
| *Pay Period: |
|
| * Province/Territory of Employment: |
|
| * Federal TD1 - Total Claim Amount: |
|
| * Prov/Terr TD1P - Total Claim Amount: |
|
| Requested additional tax deduction: |
per pay period |
| TD1(E) - annual ded for living in a prescribed zone: |
|
| Reduction in annual amount subject to income tax: |
(authorized by tax office) |
| Exempt: |
CPP
EI |