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R, or the staff of a parliamentarian. This form is valid until the matters identified are resolved. I authorize the Canada Revenue Agency to disclose to (Print name of parliamentarian) information about me on the subjects selected in the check-box area below or raised in my correspondence or communication of Year Month Day Please check (M) the appropriate box(es) Income tax matters CPP/EI matters GST/HST matters Other matters (specify): Client Identification Print full name of individual.

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