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): ________________________________________
- Date modified: