I confirm that Canadian Benefits Association, a division of Herman and Meyer Accounting Services Inc. (“CBA”) has advised me that I, or certain individuals related to me, may be eligible for certain disability-related tax benefits from the Canadian and/or provincial governments. In addition, CBA is hereby retained by the client to pursue federal and provincial personal income and excise tax refunds and/or credits (collectively “refunds”) that may be available with respect to the client’s tax filings during the previous 10 taxation years. In performing its obligations hereunder, CBA is and shall be deemed to be an independent contractor and not a partner, agent, or employee of the client. I hereby retain the CBA to pursue these benefits, on the following terms:
CBA 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 CBA deems advisable in connection with the application process (including, without limitation, Level 2 CRA Authorization), and to cooperate fully and promptly with the CBA during and following the application process. By signing below, I authorize the Canadian Benefits Association to represent me with the CRA for all income tax matters. I agree to Level 2 CRA authorization, and group ID GPF6SB, GTB3QK, GS3LK8
While the CBA does not guarantee that any party will be entitled to any benefits, Canadian Benefits Association will be entitled to a fee equal to 33% (plus GST/HST), plus applicable administrative fee of all benefits I, or any individual related to me receive. Whether in the form of refunds or credits from the CRA, a provincial agency, or otherwise, in respect of the application prepared by the CBA. I agree to notify the CBA immediately upon receipt of any such benefits by myself or any party related to me. In the event that no such benefits are received, I will not be required to make any further payment to the CBA. The Canadian Benefits Association will not be entitled to a fee in respect of any period following the time period that is subject of the application prepared by the CBA.
The Canadian Benefits Association’s fee will be due five (5) business days from the receipt of any benefits by myself or any party related to me. Any fee, or portion thereof, not paid when due will accrue interest at a rate of 2% per month (being 26.82% per year), and I will be responsible for CBA’s cost of collecting its fees. Any returned cheques will be subject to a fee of $45.00.
The client is solely responsible to provide the CBA with valid and accurate information and documentation regarding any claim for refund. Notwithstanding that CBA may ask clarification questions regarding matters that arise during its review process, CBA will not otherwise audit or verify any information or documentation submitted by the client. The client acknowledges and agrees that it is the client’s sole responsibility to provide the CBA with complete, valid and accurate information in order for CBA to claim the maximum refund that may be available. The client must retain copies of all the receipts, cancelled cheques and other supporting documentation regarding any information provided to the CBA. The CBA will treat my information in accordance with the terms of its privacy policy and this agreement. I confirm that I have been provided with a current copy of CBA’s privacy policy and acknowledge that CBA’s privacy policy may be revised from time to time by CBA. At any time, the most recent version of CBA’s privacy policy will be available upon my request.
I/we authorize Canadian Benefits Association, and the financial institution designated to effect deductions as per my/our instructions for CBA invoices representing 33% plus applicable taxes and administrative fee for CRA refunds or credit received by me/us related to CBA’s tax review. A personal pre-authorized debit (PAD) for the full amount of the services delivered will be debited from my/our specified account. A void cheque/direct deposit information will be provided to the CBA. This authority is to remain in effect until CBA has received written notification from me/us for its change or termination. I/We may obtain a sample collection form, or more information on my/our right to cancel a PAD Agreement at my/our financial institution or by visiting www.cdnpay.ca. I/We hereby waive my/our right to receive pre-notification of the amount of the amount of the PAD and agree that I/we do not require advance notice of the amount of the PADs more than 3 days before the debit is processed. The CBA may not assign this authorization, whether directly or indirectly, by operation of law, change of control or otherwise, without providing at least 10 days prior written notice to me/us. I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any PAD that is not authorized or is not constant with this PAD Agreement. To obtain a form for a Reimbursement Claim, or for information on my/our recourse rights, I/we may contact my/our financial institution or visit www.cdnpay.ca.
CBA 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 application.
Unless the CBA has advised me in writing that it has terminated this agreement, I will remain responsible for CBA’s fee. In the even that independently of CBA, I pursue an application for benefits in respect of all or part of the time period that was the subject of the application prepared by the Canadian Benefits Association. This agreement shall be governed by the laws of the province of Ontario, and the courts of the City of Toronto in the province of Ontario shall have exclusive jurisdiction over any disputes related to this agreement. I authorize and consent for my doctor to disclose my personal health information to the Canadian Benefits Association. I understand that I can refuse to sign this form.