Form 14708 - Streamlined Domestic Penalty Reconsideration Request Related To Canadian Retirement Plans Page 2

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I agree to retain all records (including, but not limited to, account statements) related to my Canadian retirement plans and all assets

subject to the 5% miscellaneous offshore penalty until six years from the date of this penalty reconsideration request. Upon request, I

agree to provide all such records to the Internal Revenue Service.

I agree that any determination made in relation to my penalty reconsideration request is final and may not be appealed.

Under penalties of perjury, I declare that I have examined this penalty reconsideration request and all accompanying schedules and

statements, and to the best of my knowledge and belief, they are true, correct, and complete.

Signature of Taxpayer

Name of Taxpayer

Date

Signature of Taxpayer

Name of Taxpayer

Date

(if joint certification)

For Estates Only

Signature of Fiduciary

Date

Title of Fiduciary

Name of Fiduciary

(e.g., executor or administrator)

For Paid Preparer Use Only

(the signature of taxpayer(s) or fiduciary is required even if this form is signed by a paid preparer)

Signature of Preparer

Name of Preparer

Date

Firm’s name

Firm’s EIN

Firm’s address

City

State

ZIP code

Telephone number

PTIN

Check if

Self-Employed

Do you want to allow another person to discuss this form with the IRS

Yes (complete information below)

Designee’s name

Telephone number

This document and any attachments must be sent to:

Internal Revenue Service

3651 South I-H 35

Stop 4305 AUSC

Attn: Streamlined Unit

Austin, TX 78741

Privacy Act and Paperwork Reduction Notice

We ask for the information on this certification by U.S. person residing in the United States for streamlined domestic offshore procedures to carry out the

Internal Revenue laws of the United States. Our authority to ask for information is sections 6001, 6109, 7801, 7803 and the regulations thereunder. This

information will be used to determine and collect the correct amount of tax under the terms of the streamlined filing compliance program. You are not

required to apply for participation in the streamlined filing compliance program. If you choose to apply, however, you are required to provide all the

information requested on the streamlined certification. You are not required to provide the information requested on a document that is subject to the

Paperwork Reduction Act unless the document displays a valid OMB control number. Books or records relating to a document or its instructions must be

retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information

are confidential, as required by section 6103. Section 6103, however, allows or requires the Internal Revenue Service to disclose or give this information

to others as described in the Internal Revenue Code. For example, we may disclose this information to the Department of Justice to enforce the tax

laws, both civil and criminal, and to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out their tax laws. We may

also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law

enforcement and intelligence agencies to combat terrorism. Failure to provide this information may delay or prevent processing your application.

Providing false information may subject you to penalties. The time needed to complete and submit the streamlined certification will vary depending on

individual circumstances. The estimated average time is: 2 hours

14708

Catalog Number 67891D

Form

(9-2016)