8171 Yonge street suite 321 Thornhill, ON L3T2C6

Phone: 1-844-585-7256
[email protected]
www.canadiandisabilitybenefits.ca

Client Benefit Retainer Agreement

Harvey Bender
I ________________________________________________, confirm that 2423561 Ontario
Limited D.B.A Canadian Disability Benefits (hereafter 2423561 Ontario Limited is "242/CDB")
has advised me that I may be eligible for certain disability-related tax benefits from the
Canadian and/or provincial governments, and I hereby retain 242/CDB to pursue these
benefits on my behalf, on the following terms:

● 242/CDB is authorized to act on my behalf in dealing with the Canada Revenue Agency
(CRA), provincial agencies, health professionals, and such other parties as may be
appropriate in connection with the application process, and to obtain and disclose
information about me from and to all such parties. I agree to sign such consent forms as
242/CDB deems advisable in connection with the application process (including, without
limitation, CRA Authorization Form T1013, attached hereto), and to cooperate fully and
promptly with 242/CDB during and following the application process.

● 242/CDB does not guarantee that I will be entitled to any benefits. I acknowledge that if
I am granted benefits, 242/CDB will be entitled to a fee equal to 25% (plus HST) of all
benefits I receive, whether in the form of refunds or credits from CRA or otherwise, in
respect of the application prepared by 242/CDB. 242/CDB will not be entitled to a fee in
respect of any period following the time period that is the subject of the application
prepared by 242/CDB.

● I agree to notify 242/CDB immediately upon receipt of any such benefits by myself. In
the event that no such benefits are received, I will not be required to make any payment
to 242/CDB.

● 242/CDB’s fee will be due five (5) business days from the receipt of any benefits by
myself. Any fee, or portion thereof, not paid when due will accrue interest at a rate of

M743141 Page 1
 8171 Yonge street suite 321 Thornhill, ON L3T2C6
Phone: 1-844-585-7256
[email protected]
www.canadiandisabilitybenefits.ca

2% per month (being 26.82% per year), and I will be responsible for 242/CDB's costs of
collecting its fees.

● 242/CDB will be entitled to make such determinations as it deems appropriate in

connection with the application process, including, without limitation, whether to amend,
delay, or withdraw the application.

● I may terminate this agreement without liability for a period of fourteen (14) days
following the date on which this agreement is signed and returned to 242/CDB. This
termination will only be valid if 242/CDB is notified in writing by mail, courier, or fax.
Notification of termination by telephone, e-mail, or online submission shall not be valid.

● I acknowledge that this agreement is governed by and construed in accordance with the
laws of the Province of Ontario and the laws of Canada applicable therein. The parties
agree to submit all of their disputes arising out of, or in connection with this agreement
to the exclusive jurisdiction of the courts of the Province of Ontario.

______________________ 905-517-9487
____________________ 05/13/2020
______________
Signature Telephone Number Date

M743141 Page 2
 Protected B
Authorizing or Cancelling a Representative when completed

Important: If you recently moved, update your address and contact information with the Canada Revenue Agency (CRA) online if you are
registered for My Account at cra.gc.ca/myaccount, by telephone at 1-800-959-8281, or in writing.
By registering for My Account, you can view, add, modify, or cancel your authorized representatives. To immediately cancel a
representative, call us at 1-800-959-8281.
Complete a separate Form T1013 for each account (Part 1) and representative (Part 2).
Do not complete a new form every year if there are no changes.
See the attached information sheet if you need help completing this form.

Part 1 – Taxpayer information

Complete the line that applies.
SIN, TTN or ITN
225488824 First name: Harvey Last name: Bender
Trust account number
T Trust name:
T5 filer identification number
H A Filer name:

Part 2 – Representative information and authorization

Complete section A or B, as applicable.

A. Authorize online access for all tax years (including access by telephone, in person, and in writing)
RepID
First name: Last name:
GroupID
G Group name:
Business number (BN)
Business name: Canadian Disability Benefits
7 7 5 7 2 5 3 2 8
Representative mailing address: 8171 Yonge street suite 321 Thornhill, ON L3T2C6

Enter the level of authorization (level 1 or 2): 2

Notes
A representative of a trust account will have access to all tax years with no online access.
If you have a "care of" address on your account, we will send you a letter asking you to call the CRA to authorize the online access.

B. Authorize access by telephone, in person, and in writing (no online access)

First name: Last name:

Business name:

Telephone: Ext: Fax:

Tick the appropriate box and indicate the level of authorization:

All tax years (past, present, and future) Level of authorization (level 1 or 2)
or
Specific tax year(s) with the level of authorization (level 1 - disclose, or level 2 - disclose/request changes) indicated for each tax year.

Tax year(s)
Level of authorization

Page 3
M743141
T1013 E (16) (Vous pouvez obtenir ce formulaire en français à arc.gc.ca/formulaires ou en composant le 1-800-959-7383.)
 Protected B when completed
Part 3 – Authorization expiry date
Enter an expiry date, if applicable. Your representative's access to your information will stay Year Month Day
in effect until you or your representative cancel it, or we are notified of your death.

Part 4 – Cancel your representative

Complete this section to cancel your representative(s) and remove their access to your information. Tick the appropriate box.

Cancel all representatives

or
Cancel the representative listed below:

RepID
First name: Last name:
GroupID
G Group name:
Business number (BN)
Business name:

Go to My Account at cra.gc.ca/myaccount to view all representatives with access to your information.

Part 5 – Signature and date

If you are the taxpayer, you must sign and date this form.
If you are the legal representative, you must tick the box below, and sign and date this form.

I am the legal representative for this taxpayer or estate/trust (executor/administrator, power of attorney, the legal guardian
or the trustee or custodian of this trust account).
Important: You must send a complete copy of the legal document giving you the authority to act in this capacity to the
taxpayer’s tax centre. Read the attached information sheet for tax centre addresses.
If two or more legal representatives are acting jointly on the taxpayer's behalf, each legal representative must sign
below.

Harvey Bender
Name of taxpayer, legal representative(s) or corporate officer(s) Name of corporation and title of corporate officer(s)

Year Month Day

X 05/13/2020
Signature of taxpayer, legal representative(s), or corporate officer(s) Date of signature
a parent (if taxpayer is under the age of 16),
a witness (when signed with a mark)

If your representative has not electronically submitted this form on your behalf then it must be submitted within six months of the date of
signature. If not, it will not be processed.

Personal information is collected under the Income Tax Act to administer tax, benefits, and related programs. It may also be used for any purpose related to
the administration or enforcement of the Act such as audit, compliance and the payment of debts owed to the Crown. It may be shared or verified with other
federal, provincial/territorial government institutions to the extent authorized by law. Failure to provide this information may result in your request not being
accepted. Under the Privacy Act, individuals have the right to access their personal information and request correction if there are errors or omissions.
Refer to Info Source at cra.gc.ca/gncy/tp/nfsrc/nfsrc-eng.html, Personal Information Banks CRA PPU 005, CRA PPU 015, CRA PPU 063, CRA PPU 140,
CRA PPU 178 and CRA PPU 218.

BARCODE

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