U.S. Information Return for Beneficiaries of                                                 OMB No. 1545-0074
Form 8891                       Certain Canadian Registered Retirement Plans 
(Rev. December 2012)                                       ▶ Attach to Form 1040.                                 
                            For calendar year 20   , or tax year beginning         , 20   , and ending                , 20   . Attachment   
Department of the Treasury      ▶ Information about Form 8891 and its instructions is at www.irs.gov/form8891.                 Sequence No. 139 
Internal Revenue Service 
Name as shown on Form 1040                                                                                            Identifying number (see instructions)

Address

1      Name of plan custodian                                                      2    Account number of plan 

3      Address of plan custodian                                                   4    Type of plan (check one box): 
                                                                                            Registered Retirement Savings Plan (RRSP) 
                                                                                            Registered Retirement Income Fund (RRIF) 

5      Check the applicable box for your status in the plan (see Definitions in the instructions): 
       Beneficiary
       Annuitant (Complete only lines 7a, 7b, and 8.)

6 a    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?            .    . . . .    .   . .        . . .  ▶     Yes          No

b      If “Yes,” enter the first year the election came into effect                          and go to line 7a. If “No,” go to line 6c.

c      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            .    . . . .    .   . .        . . .  ▶

7 a    Distributions received from the plan during the year. Enter here and include on Form 1040, line
       16a . .       .   .  . . . . . .          . . . . . . .             . . . . .    . . . .    .   . .        . .    7a 

b      Taxable distributions received from the plan during the year. Enter here and include on Form
       1040, line 16b       . . . . . .          . . . . . . .             . . . . .    . . . .    .   . .        . .    7b 

8      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 .            . .        . .    8 

9      Contributions to the plan during the year       . . . .             . . . . .    . . . .    .   . .        . .    9 

10     Undistributed earnings of the plan during the year: 

a      Interest income. Enter here and include on Form 1040, line 8a             . .    . . . .    .   . .        . .    10a 

b      Total ordinary dividends. Enter here and include on Form 1040, line 9a             . . .    .   . .        . .    10b 

c      Qualified dividends. Enter here and include on Form 1040, line 9b .              . . . .    .   . .        . .    10c 

d      Capital gains. Enter here and include on Form 1040, line 13             . . .    . . . .    .   . .        . .    10d 

e      Other income. Enter here and include on Form 1040, line 21. List type and amount ▶

                                                                                                                         10e 
For Paperwork Reduction Act Notice, see instructions.                              Cat. No. 37699X                           Form 8891 (Rev. 12-2012) 

Form 8891 (Rev. 12-2012)                                                                                                      Page 2 

Section references are to the Internal Revenue Code.              Specific Instructions 
Future Developments                                               All amounts listed must be in U.S. dollars. 
For the latest information about developments related to Form 
8891 and its instructions, such as legislation enacted after they Name and Address
were published, go to www.irs.gov/form8891.                       Enter your name and address as shown on Form 1040. Even if 
                                                                  you are filing a joint Form 1040 with your spouse, enter only 
General Instructions                                              your name. 
Purpose of Form                                                   Identifying number 
Form 8891 is used by U.S. citizens or residents (a) to report     Enter your U.S. social security number (SSN) or individual  
contributions to Canadian registered retirement savings plans     taxpayer identification number (ITIN). Do not enter a Canadian 
(RRSPs) and registered retirement income funds (RRIFs), (b) to    identifying number. 
report undistributed earnings in RRSPs and RRIFs, and (c) to      Beneficiaries 
report distributions received from RRSPs and RRIFs. See  
Notice 2003-75, which is available at IRS.gov.                    A beneficiary who previously made the election to defer income 
                                                                  on the plan or is making it initially by checking the box on line 6c 
Form 8891 also can be used to make an election pursuant to        must only complete lines 1 through 8 of the  form. 
Article XVIII(7) of the U.S.-Canada income tax treaty to defer 
U.S. income tax on income earned by an RRSP or an RRIF that       Annuitants 
has been accrued, but not distributed. Taxpayers who have not 
previously made the election can make it on this form by          If you are treated as an annuitant for purposes of this form (see  
checking the box on line 6c.                                      Definitions), you should complete only lines 1 through 5, 7a, 7b, 
                                                                  and 8. 
Who Must File 
                                                                  Line 6(a) 
Form 8891 must be completed and attached to Form 1040 by 
any U.S. citizen or resident who is a beneficiary of an RRSP or   If the election you made previously was made under Rev. Proc. 
RRIF. Do not file Form 8891 by itself.                            89-45, check the “No” box. If an election (other than an election 
                                                                  under Rev. Proc. 89-45) was made for an RRSP, and amounts 
A U.S. citizen or resident who is an annuitant of an RRSP or      from the RRSP were rolled over tax-free to an RRIF or another 
RRIF must file the form for any year in which he or she receives  RRSP, the election is considered to have been made for the 
a distribution from the RRSP or RRIF.                             plan which received the tax-free rollover. 
A separate Form 8891 must be filed for each RRSP or RRIF 
for which there is a filing requirement. If you and your spouse   Line 6(c) 
are both required to file Form 8891, each of you must complete    If you did not make the election under Article XVIII to defer 
and attach a separate Form 8891 to Form 1040, even if you file    income tax on income earned by an RRSP or an RRIF in a 
a joint return.                                                   previous year, you cannot make a late election on Form 8891.  
                                                                  However, you may be able to seek relief from the IRS for failure 
Definitions                                                       to timely elect the deferral of income on Form 8891 in an earlier 
Beneficiary. A beneficiary of an RRSP or RRIF is an individual    year. 
who is subject to current U.S. income taxation on income 
accrued in the RRSP or RRIF or would be subject to current        Line 7(b) 
income taxation had the individual not made the election under    For information on figuring taxable distributions, see section 72 
Article XVIII(7) of the U.S.-Canada income tax treaty to defer    and Pub. 939, General Rule for Pensions and Annuities. 
U.S. income taxation of income accrued in the RRSP or RRIF. 
Annuitant. For purposes of this form, an annuitant of an RRSP 
or RRIF is an individual who is designated pursuant to the RRSP   Paperwork Reduction Act Notice 
or RRIF as an annuitant and is not also a beneficiary as defined  We ask for the information on this form to carry out the Internal 
above.                                                            Revenue laws of the United States. You are required to give us 
                                                                  the information. We need it to ensure that you are complying 
Record Retention                                                  with these laws and to allow us to figure and collect the right 
Taxpayers must retain supporting documentation relating to the    amount of tax. 
information reported on Form 8891, including Canadian forms       You are not required to provide the information requested on 
T4RSP, T4RIF, or NR4, and periodic or annual statements           a form that is subject to the Paperwork Reduction Act unless 
issued by the custodian of the RRSP or RRIF.                      the form displays a valid OMB control number. Books or 
                                                                  records relating to a form or its instructions must be retained as 
Other Reporting Requirements                                      long as their contents may become material in the 
Pursuant to section 6048(d)(4), annuitants and beneficiaries      administration of any Internal Revenue law. Generally, tax  
who are required to file Form 8891 will not be required to file   returns and return information are confidential, as required by  
Form 3520 and will not be subject to the associated penalties     Internal Revenue Code section 6103. 
described in section 6677 on such RRSPs or RRIFs.                 The average time and expenses required to complete and file 
You may be required to file Form TD F 90-22.1, Report of          this form will vary depending on individual circumstances. For 
Foreign Bank and Financial Accounts. You may also be required     the estimated averages, see the instructions for your income tax 
to file Form 8938, Statement of Specified Foreign Financial       return. 
Assets, for other Canadian assets not reported on this Form       If you have suggestions for making this form simpler, we  
8891. For more information, see the instructions for Schedule B   would be happy to hear from you. See the instructions for your 
(Form 1040A or 1040) at www.irs.gov/form1040, and the             income tax return. 
instructions for Form 8938 at www.irs.gov/form8938.