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T P -1.R-V ( 2016-05)
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Request for an Adjustment

to an Income Tax Return Erase

Complete this form if you wish to make changes to a personal income tax return that
you have already filed.
Complete a separate form for each taxation year for which you are requesting
an adjustment.
Send the form and your supporting documents (receipts, information slips, schedules,
etc.) separately from any income tax return to Revenu Qubec at one of the
following addresses:
3800, rue de Marly, Qubec (Qubec) G1X 4A5
C. P. 3000, succursale Place-Desjardins, Montral (Qubec) H5B 1A4
To prevent any delays in processing your application, be sure to:
sign your request in Part 3. If your representative has signed the request,
attach a power of attorney (form MR-69-V, Power of Attorney, Authorization
to Communicate Information, or Revocation, or a similar document, unless you
have already filed it and the document is still valid);
provide all supporting documents. If your request for an adjustment concerns
a line from your income tax return for which an amount has already been claimed
but for which supporting documents were not provided, please provide those
documents as well as any documents regarding the requested adjustment; and
provide clear and detailed explanations in Part 2.
Important
As a rule, if you are requesting an adjustment to claim a refund, your request must
concern an income tax return filed for one of the ten calendar years preceding the
year in which you file your request. For example, if you want to request an adjustment
to your 2008 income tax return in order to claim a refund, you must file your request
before January 1, 2019. In some cases, however, such as the solidarity tax credit, the
ten-year limit does not apply.
Social insurance number
Taxation year

1 Information about the applicant

Last name First name

Address

Postal code

Name of representative (where applicable) Form MR-69-V (or similar document)
Enclosed Already filed

2 Information about the adjustment

"Completing your request for an adjustment
If the space provided is insufficient, attach another sheet giving the information requested. See Completing adjustment" on the next page.

Line number Amount shown on Amount of Montant corrig

return or on most
on income Title of line recent notice of adjustment Revised amount (Do not use
tax return assessment requested this column.)

Explanations concerning the adjustment

3Certification
I certify that the information provided on this form and in the attached documents is, to the best of my knowledge, accurate and complete.

Name of representative, where applicable

Signature of individual or representative Date Area code Telephone Area code Telephone (work) Extension

13H8 ZZ 49517256
Print the form Print information
 T P -1.R-V ( 2016-05)
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Information

Completing your request for an adjustment

In Part 2, enter only the information concerning the line for which you are requesting an adjustment. We will calculate any other
amounts in your income tax return that may be affected by your request. Note that if the adjustment results in your having a
balance payable, you will have to pay interest on that balance, calculated as of the date the balance was due.

In the Revised amount column, enter the amount you would have entered on the line for which you are requesting an
adjustment if you had taken into account the amounts covered by your request (and by any prior request for the
line concerned) when you filed your income tax return. For example, if you are sending us receipts for medical expenses
totalling $3,000 for the 2010 taxation year, you claimed no deduction for medical expenses in your 2010 income tax return and
your family income for 2008 was $60,000:
enter 0 in the Amount shown on return or on most recent notice of assessment column;
enter $1,200 in the Revised amount column, that is, the portion of the medical expenses that exceeded 3% of your family
income ($3,000 [3% x $60,000]);
enter $1,200 in the Amount of adjustment requested column ($1,200 0); and
give a breakdown of your calculation in the Explanations concerning the adjustment section.

Where your request requires you to calculate a deduction or tax credit, you must first determine the revised amount as explained
above. You must then determine the amount of the adjustment requested, which is the difference between the revised amount
and the amount in your income tax return for the year concerned or on your most recent notice of assessment for that year.

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13H9 ZZ 49517257