U.S. Information Return for Beneficiaries of
OMB No. 1545-0074
Certain Canadian Registered Retirement Plans
(Rev. December 2006)
Department of the Treasury
Internal Revenue Service
Attach to Form 1040.
See instructions on back of form.
Name shown on Form 1040
Identifying number (see instructions)
Name of plan custodian
Account number of plan
Address of plan custodian
Type of plan (check one box):
Registered Retirement Savings Plan (RRSP)
Registered Retirement Income Fund (RRIF)
Check the applicable box for your status in the plan (see Definitions in the instructions):
Annuitant (Complete only lines 7a, 7b, and 8.)
Have you previously made an election under Article XVIII(7) of the U.S.–Canada income tax treaty to
defer U.S. income tax on the undistributed earnings of the plan?
If “Yes,” enter the first year the election came into effect
and go to line 7a. If “No,” go to line 6c.
If you have not previously made the election described on line 6a above, you can make an irrevocable
election for this year and subsequent years by checking this box
Distributions received from the plan during the year. Enter here and include on Form 1040,
Taxable distributions received from the plan during the year. Enter here and include on
Form 1040, line 16b
Plan balance at the end of the year. If you checked the “Annuitant” box on line 5, the “Yes” box
on line 6a, or the box on line 6c, stop here. Do not complete the rest of the form
Contributions to the plan during the year
Undistributed earnings of the plan during the year:
Interest income. Enter here and include on Form 1040, line 8a
Total ordinary dividends. Enter here and include on Form 1040, line 9a
Qualified dividends. Enter here and include on Form 1040, line 9b
Capital gains. See the instructions for Form 1040, line 13, for how to report
Other income. Enter here and include on Form 1040, line 21. List type and amount
For Paperwork Reduction Act Notice, see page 2.
Cat. No. 37699X