3) Total: Other fixed income securities Total: Growth securities Common shares Description Date of acquisition ACB ($) Annual dividend Quantity Market value ($) Total ($) 1) 2) 3) 4) Total Perpetual preferred shares Description Date of acquisition ACB ($) Rate of return Quantity Market value ($) Total ($) 1) 2) 3) 4) Total Growth securities mutual funds Description Date of acquisition MER ACB ($) Number of units Market value ($) ($) 1) 2) 3) 4) Income trusts Description Date of acquisition ACB ($) Annual distributions ($) Quantity Market value ($) ($)
Description Date of acquisition ACB ($) Rate of return Maturity Quantity Market value ($) Total ($) 1) 2) 3) Fixed income mutual funds Description Date of acquisition ACB ($) Rate of return Maturity Quantity Market value ($) 1) 2) 3) Total: Other fixed income securities Growth securities Common shares Description Date of acquisition ACB ($) Annual dividend Quantity Market value ($) Total ($) 1) 2) 3) 4) Total Perpetual preferred shares Description Date of acquisition ACB ($) Rate of return Quantity Market value ($) Total ($) 1) 2) 3) 4)
Total Growth securities mutual Description Date of acquisition MER ACB ($) Number of units Market value ($) Total ($) 1) 2) 3) 4) Income trusts Description Date of acquisition ACB ($) Annual distributions ($) Quantity Market value ($) Total ($) 1) 2) 3) Note: The ACB should be adjusted downward each year to reflect capital distributions. growth securities Total: TFSA: NOTE 7: Advances receivable NOTE 8: Principal residence Address Year of acquisition Price paid ($) Municipal evaluation ($) Market value ($) Note: Include the paid for major improvements or renovations. If the market value differs from the municipal evaluation, identify the evaluation method.
Common shares Description Date of acquisition ACB ($) Annual dividend Quantity Market value ($) Total ($) 1) 2) 3) 4) Total Perpetual preferred shares Description Date of acquisition ACB ($) Rate of return Quantity Market value ($) Total ($) 1) 2) 3) 4) Total Growth securities mutual Description Date of acquisition MER ACB ($) Number of Market ($) Total ($) 1) 2) 3) 4) Total Income trusts Description Date of acquisition ACB ($) Annual distributions ($) Quantity Market value ($) Total ($) 1) 2) Total Note: The ACB should be adjusted downward each year to reflect capital distributions. Other growth securities
Total: RRSP or RRIF: NOTE 15: Registered Pension Plan Defined benefits Participant rate Pension accumulation rate Earnings subject to contributions (S) Current ($) Other features 1) 2) Defined contribution Participant rate Employer contribution rate Earnings subject to contributions (S) Market value ($) features 1) Investment characteristics: 2) Investment characteristics: NOTE 16: Locked-In Retirement Account or Life Income Fund Liquid securities Savings bonds Issuer Series Interest rate Maturity Face value ($) Accrued ($) 1) 2) Term deposits or guaranteed investment certificates maturing in less than 1 year Financial institution Date of deposit Date of maturity Interest rate Accrued value ($) 1) 2)
Total LIRA or LIF: NOTE 17: Registered Education Savings Plan or Registered Disability Savings Plan Note: The RESP should only appear in the subscriber’s personal balance and the value is equal to contributions made. The total value of the RDSP should appear in the beneficiary’s personal balance sheet. NOTE 18: Accounts payable Description Maturity date Interest rate Amount ($) 1) 2) 3) 4) NOTE 19: Personal loans Description Date of loan Date of maturity Payments ($) Interest rate Original amount ($) Balance ($) 1) 2) 3) 4) NOTE 20: Mortgage Lender Description Date of loan Date of maturity Payments ($) Frequency Interest rate Original amount ($) Balance ($) 1) 2) 3) NOTE 21: Investor profile Asset category Registered investments ($) % Non-registered investments ($) % Combined (%) Profile (%) Gap (%) Liquid securities Fixed-income securities Growth securities
NOTE 22: Life, disability and other insurance contracts a) Life insurance Issuer Underwriting year Type of contract Adherent Insured Beneficiary ($) Annual premium ($) Cash surrender value ($) Adjusted cost base ($) Capitalization fund Death benefit Comments: b) Disability insurance Issuer Underwriting year Premium ($) Waiting period Monthly income ($) % indexation Profession protected for (years) Other features Comments: c) Critical illness, long-term care insurance and other insurance coverage Issuer Underwriting year Premium ($) Insured capital ($) Illnesses covered Comments: