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REQUEST BY A NON-RESIDENT OF CANADA FOR A CERTIFICATE OF COMPLIANCE
RELATED TO THE DISPOSITION OF TAXABLE CANADIAN PROPERTY
Tick (X) the box that applies to you |XX| Proposed disposition |_| Completed disposition
Vendor (non-resident)
Last name (print) First name and initial (print) Date of Birth Date of departure from Canada
Year Month Day Year Month Day
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Present address Social insurance number or temporary tax number
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Business Number (BN)
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Representative - name and address (see note below) Telephone and fax number
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Note: By completing this information, you authorize the person named to act as your representative in matters concerning this
request.
Purchaser
Last name First name and initial Telephone
INTERCORP EXCELLE INC. 416-744-2124
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Present address
1880 ORMONT DR., TORONTO, ON, M9L 2V4
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Representative's name and address Telephone and fax number
DAVID MUHA, WILDEBOER RAND THOMSON et al 416-361-1790 (f)
Suite 810, 1 FIRST CANADIAN PLACE, TORONTO, ON M5X 1A9 416-361-2933 (tel)
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1. If you previously filed Form T2062 or Form T2062A in this calendar year, state the name of the tax |_| Yes |X| No
services office where you filed it, and give the name and address of the purchaser(s).___________________________________________
2. Is the disposition subject to an election under section 85 (transfer of property to a corporation)? |_| Yes |X| No
3. Do you hold or plan on holding a mortgage as a result of the disposition? |_| Yes |X| No
4. Have you received income, including rents, royalties, or lease payments, from the property? |_| Yes |X| No
If yes, complete the following:
|_| Non resident tax was withheld:
Give the name and address of person who withheld the tax. ___________________________________________________________________
|_| Non resident tax was not withheld: (attach income statements
State the period when income was received from the property. _________________ to _________________ that show the amount of
(year, month, day) (year, month, day) gross income)
If no, state the use of the property during the period of ownership._____________________________________________________________
5. If you have outstanding balances for taxes, including income or excise taxes, custom duties, or the goods & services tax/
harmonized sales tax (GST/HST), give the identification or account number(s) for the outstanding balances._______________________
6. State the last tax year for which you filed a Canadian income tax return, if applicable: __________
7. Is the disposition of property to a person with whom you are not dealing at arm's length, or is it a
gift inter-vivos? |_| Yes |X| No
If yes, and the disposition is at less than fair market value, enter the fair market value at the time
of disposition in column (1) below.
Details of property (refer to instructions on page 1 for more information)
Date or Vendor's
proposed date of disposition acquisition date Description of property
Year Month Day Year Month Day
(1) (2) (3) (4) (5)
Proceeds of disposition Adjusted cost base Gain or (loss). Exemptions Net gain or (loss).
Column (1) less column (3) Column (3) less column (4)
$ $ $ $ $
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Payment of tax. Enter 25% of net gain. $
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Certification
I, _______________________, certify that the information given on this form is, to the best of my knowledge, correct and complete.
Name
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Date (Authorized person's signature) (Person or officer)
Appendix A - Declaration of Residency
TO: Canada Customs and Revenue Agency
AND TO: Intercorp Excelle Inc.
The undersigned, a tendering holder of Common Shares, hereby represents
to Intercorp Excelle Inc. and to the Canada Customs and Revenue Agency that the
undersigned is liable to tax in the United States and is not, and has not been
at any time in the past ten (10) years, a resident of Canada for the purposes of
the Income Tax Act (Canada).
SIGNED before me at the of )
in )
the , this )
day of , 2001. )
)
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) Name:
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Witness Address:
Appendix B - Adjusted Cost Base and Proceeds of Disposition
The broker who is the registered shareholder of my common shares is (if you do
not hold your shares through a broker, leave this section blank):
Name:
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Address:
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Date of Acquisition Number of Common Total Acquisition Cost ($US)
Shares Acquired (including reasonable costs of acquisition,
including brokers' commissions and fees)
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Total Number of Common
Shares Acquired: __________
Total Acquisition Cost: $__________
Total Proceeds of Disposition is equal to the Total Number of Common Shares
Acquired multiplied by US $1.15.
INSTRUCTIONS FOR COMPLETING FORM T2062
"Request by a Non-resident of Canada for a Certificate of Compliance
Related to the Disposition of Taxable Canadian Property"
As described in the Offer to Purchase under the heading "Shareholders not
Resident in Canada", each non-resident of Canada disposing of Common Shares must
notify the Canada Customs and Revenue Agency (the "CCRA"), in a prescribed form,
of the particulars of the disposition. The form prescribed by the CCRA is the
attached Form T2062 "Request by a Non-resident of Canada for a Certificate of
Compliance Related to the Disposition of Taxable Canadian Property".
The information that is available to the Company has been entered on the Form
T2062 on your behalf. Instructions for completing the remainder of Form T2062
are set out below.
The CCRA will issue a clearance certificate in respect of your disposition of
Common Shares provided that you have complied with the requirements imposed by
the Income Tax Act (Canada). As set out in the Offer to Purchase, please be
advised that the Company will withhold and remit to the Receiver General for
Canada 25% of the proceeds payable to you on the disposition, unless it receives
a clearance certificate from the CCRA within 30 days after the end of the month
in which the Closing Date occurs.
Please complete and sign the enclosed form as soon as possible, and send it to:
Canada Customs & Revenue Agency
Toronto North Tax Services Office
Section 116 Clearance Certificate Applications -
International Audit Division
5001 Yonge Street
North York, ON
M2N 6R9
Attention: Ms. Ray Filatovs
Instructions for Completion
1. Enter your name, address, date of birth and date of departure from
Canada (if you were a former resident of Canada) on the Form T2062. If
the CCRA has previously issued you a "Temporary Tax Number" or
"Non-resident Corporation Business Number" (you will have been issued
such a number if you have previously filed a Canadian tax return)
please enter this number at the top of the Form T2062, where indicated.
2. Answer Part #1 on the Form T2062 by indicating whether you previously
submitted a Form T2062 or T2062A to the CCRA in 2001. If you have
previously submitted a Form T2062 or T2062A, provide the requested
details.
3. You need not answer Parts #2, #3, or #4 of the Form T2062.
4. Answer Part #5 on the Form T2062 by indicating whether you have any
outstanding balances for Canadian taxes. If you have any outstanding
tax balances, provide the requested details.
5. Answer Part #6 on the Form T2062 by indicating when you last filed a
Canadian income tax return, if applicable.
6. If you are a resident of the United States for tax purposes, and each
of the statements contained in the attached form entitled "Appendix A,
Declaration of Residency" are accurate in your particular case, sign
the Declaration where indicated. Please note that you must sign the
Declaration before a witness, who must also sign to verify your
signature. If you are not a US resident for tax purposes, or if all of
the statements in the Declaration are not accurate in your particular
case, please consult your personal tax advisor for further
instructions.
7. Complete the attached form entitled "Appendix B, Adjusted Cost Base and
Proceeds of Disposition". You must provide the date of acquisition and
the acquisition cost (US$) in respect of each Common Share to be
disposed of pursuant to the offer to purchase - if you need more room,
please attach a separate sheet. You must also include, at the top of
Appendix B, the name of the broker who is the registered holder of your
shares.
8. Sign and date the bottom of the Form T2062, where indicated.
If you have followed the instructions set out above, you need not complete Part
#7 of the Form T2062, and you need not provide the CCRA with copies of any
documents other than those discussed in these Instructions.
If any of the information on the enclosed Form T2062 is not correct, or if you
require further assistance in completing the Form T2062, please contact your
personal tax advisors for further instructions.