14708 Streamlined Domestic Penalty Reconsideration Request Rel

Form

14708

(June 2015)

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Department of the Treasury - Internal Revenue Service

OMB Number
1545-2241

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 www.irs.gov.
Name(s) of taxpayer(s)

TIN(s) of taxpayer(s)

Mailing address of taxpayer(s)

Telephone number of taxpayer(s)
Email address 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:

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Line 1. Previously Reported Miscellaneous Offshore Penalty

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Line 2. Revised Miscellaneous Offshore Penalty

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Line 3. Requested Refund of Miscellaneous Offshore Penalty (line 1 minus line 2)

3.

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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.
Name of
Financial Institution

Address of
Financial Institution

Account
Number

Year-End Balance For
Year With Highest
Account Balance
(State In U.S. Dollars)

Catalog Number 67891D

www.irs.gov

Form 14708 (6-2015)

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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 (if joint certification)

Name of Taxpayer (if joint certification)

Date

For Estates Only
Signature of Fiduciary

Title of Fiduciary (e.g., executor or administrator)

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Date

Name of Fiduciary

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

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Catalog Number 67891D

www.irs.gov

Form 14708 (6-2015)