ARCHIVED CD 2001-003: Appendix B

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Statement of Qualifying Retroactive Lump Sum Payments (QRLSP)

A QRLSP is a lump-sum payment paid to an individual in a year and that relates to one or more preceding years. Generally, a lump-sum payment is included in income in the year the recipient receives it. This may result in a greater tax liability than if the payment had been received in the year or years to which it related. A special tax calculation is available to individuals who receive SQRLSP. The special calculation applies if the total of all QRLSPs is $3,000 or more (for recalculation of federal income tax) or $300 or more (for recalculation of Québec income tax). Attach a copy of this form to your income tax return for the year of payment to ask for a special tax calculation if the amount shown under number 4) is $3,000 or more (for recalculation of federal income tax) or if the total of numbers 4) and 5) is $300 or more (for recalculation of the Québec income tax when using the general income tax return.) For Quebec income tax, please check box 404 on your income tax return. This form then replaces form TP-766.2.V.

Name of Recipient _____________________
Social Insurance Number _______________
Year of payment _________

Description of QRLSP and reason for payment

Total amount, principal and interest (current and prior years) 6850
Total principal (current and prior years) 6851
Total interest (current and prior years)
Total principal (prior years only)
Total interest (prior years only)

Breakdown of principal by year (for the recalculation of Federal and Québec income tax)

1985 - 6859 __________
1986 - 6860 __________
1987 - 6861 __________
1988 - 6862 __________
1989 - 6863 __________
1990 - 6864 __________
1991 - 6865 __________
1992 - 6866 __________
1993 - 6867 __________
1994 - 6868 __________
1995 - 6869 __________
1996 - 6870 __________
1997 - 6871 __________
1998 - 6872 __________
1999 - 6873 __________
2000 - 6874 __________

Breakdown of interest by year (for the recalculation of Quebec income tax only)

1985 __________
1986 __________
1987 __________
1988 __________
1989 __________
1990 __________
1991 __________
1992 __________
1993 __________
1994 __________
1995 __________
1996 __________
1997 __________
1998 __________
1999 __________
2000 __________

Payor (Pay Office, Department, Paylist): ________________________________________

T-1198(E) (Canada Customs and Revenue Agency (CCRA) Form Number) TP-766.2-V ( Ministère du Revenu du Québec (MRQ) Form Number)