CAPITAL GAINS (LOSSES) STATEMENT
       
Name _______________________________
 
S.I.N. _______________________
Year _______
 
Description of asset disposed of in year: ___________________________________________________________________
 
Date of acquisition
__________, 19______
Date of disposal
__________, 20______
Original cost of asset
_______________
Proceeds on disposal
  _______________  
Outlays (i.e. broker, lawyer, other)
  _______________  
       

       
Description of asset disposed of in year: ___________________________________________________________________
 
Date of acquisition
__________, 19______
Date of disposal
__________, 20______
Original cost of asset
_______________
Proceeds on disposal
  _______________  
Outlays (i.e. broker, lawyer, other)
  _______________  
       

     
Description of asset disposed of in year: ___________________________________________________________________
 
Date of acquisition
__________, 19______
Date of disposal
__________, 20______
Original cost of asset
_______________
Proceeds on disposal
  _______________  
Outlays (i.e. broker, lawyer, other)
  _______________  
       

       

REMINDER: Contact your financial advisor/broker as soon as possible to authorize him/her to
provide us with any information we may be needing to prepare your personal income tax return.