Department of the Treasury - Internal Revenue Service
Streamlined Domestic Penalty Reconsideration
Request Related to Canadian Retirement Plans
Note: Before completing this form, please review the “Streamlined Filing Compliance Procedures for U.S. Taxpayers Residing in the
United States Frequently Asked Questions and Answers” on
Name(s) of taxpayer(s)
TIN(s) of taxpayer(s)
Mailing address of taxpayer(s)
Telephone number of taxpayer(s)
Note: If spouses previously submitted a joint certification, both spouses must sign this form. If this reconsideration request is a joint
request, the statements will be considered made on behalf of both spouses, even though singular pronouns are used.
In my original Form 14654, Certification by U.S. Person Residing in the United States for Streamlined Domestic Offshore Procedures, I
included the value of my interest in one or more Canadian retirement plans described in Rev. Proc. 2014-55 (“Canadian retirement
plans”) in the Highest Account Balance/Asset Value and paid the 5% miscellaneous offshore penalty on my Canadian retirement plans.
I certify that I am an “eligible individual” as defined in section 4.01 of Rev. Prov. 2014-55.
I have reviewed my original Form 14654, Certification by U.S. Person Residing in the United States for Streamlined Domestic Offshore
Procedures, and the documents I relied upon in preparing my certification. I have recomputed the Highest Account Balance/Asset
Value and the Miscellaneous Offshore Penalty for my 3-year covered tax return period and 6-year covered FBAR period by removing
the value of my Canadian retirement plans as follows:
Line 1. Previously Reported Miscellaneous Offshore Penalty
Line 2. Revised Miscellaneous Offshore Penalty
Line 3. Requested Refund of Miscellaneous Offshore Penalty
(line 1 minus line 2)
If your revised Highest Account Balance/Asset Value is for a year different from the Highest Account Balance/Asset Value in your
original certification, please note the change below:
Original Highest Account Balance/Asset Value year
Revised Highest Account Balance/Asset Value year
Please identify your Canadian retirement plans below. If you need more space, you may attach additional pages to this form.
Year-End Balance For
Year With Highest
(State In U.S. Dollars)
Catalog Number 67891D