SCHEDULE 5
(Section 5)

FORM OF NOTICE OF APPEAL

in the tax court of canada

In re the Employment Insurance Act

BETWEEN:
Appellant,

and

the Minister of National Revenue,

Respondent.

notice of appeal

	Notice of appeal is hereby given by (here insert name and full postal address of Appellant) ............................................ ............................................................................. from

Applies to a	(i) the decision of the Respondent on an appeal made to the Respondent on the (here
decision		insert the date the appeal was made) ....... ...... day of .......................................
on an appeal		to decide whether (here describe question decided by the Respondent and the Respondent's
under 		decision with respect to it) 
s. 91 E.I. Act 		and that 	decision was communicated to the Appellant on  the (here insert the date of mailing
		 of the decision) .............................. day of ................

Applies to a     (ii)	 the decision of the Respondent on an appeal made to the Respondent for the reconsideration of
decision on           an an an appeal        		  assessment made on the (here  insert  the date of
under s. 92           the assessment) ................. day of...............
E.I. Act        		whereby  (here  describe  assessment  that  was appealed for reconsideration)
 ...................... ...................................................................................................................... and the decision of 
the Respondent on the reconsideration was that (here insert the decision made on the reconsideration of
 the assessment) ........................................................................................................................ which decision 
was communicated to the Appellant on the (here insert the date of mailing of the decision) 
..................... day of ..............

A. 	Statement of Facts

(Here set out in consecutively numbered paragraphs a statement of the allegations of fact.)

B. 	The Reasons which the Appellant Intends to Submit

(Here set out the reasons on which the Appellant intends to rely.)

C. 	Address for Service

	(Here set out the address for service of documents: (*)
(a) name and address of Appellant’s counsel, if any, or
(b) name and address of Appellant’s agent, if any.)

Dated at (city, town or village), this ____ day of ______________ 20___

(*) If the Appellant is not represented by counsel or an agent, the address given at the commencement of the notice of appeal shall be the Appellant’s address for service.

(SCHEDULE AS AMENDED BY SOR/98-8, s. 12; SOR/2007-146, s. 9.)