Home telephone number
Name (last, rst, initial(s)) Social Insurance Number
Address
( )
City Province Postal code Business telephone number
( )
Individual account number and name
Name of TFSA issuer
TFSA issuer’s address
$ or %or
Social Insurance Number
Individual account number and name
Name of TFSA issuer
TFSA issuer’s address
Spouse’s name (last, rst, initial(s))
Date (dd/mm/yyyy) Holder’s signature
X
TFSA identication number and name
Transferees name
Date (dd/mm/yyyy) Authorized person’s signature
X
Position or ofce
Date (dd/mm/yyyy) Spouse’s signature
X
_______________
(dateoftransfer)
Transferor’s name
Date (dd/mm/yyyy) Authorized person’s signature
X
Position or ofce
Page 1 of 2
4378-E-07-09
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Transfer from a Tax-Free Savings Account (TFSA) to another TFSA on breakdown
of marriage or common-law partnership
• Transfersdocumentedinthisformmustbemadedirectlyfromaholder’sTFSAtotheTFSAoftheholder’sspouse.
• Atransferofpropertythatisnotmadeunderanordercanimpactboththeholder’sandthespouse’sTFSA
contributionroom.
AttachacopyoftheorderONLYifunabletoobtainthespousessignature.Somefinancialinstitutionsmayrequest
supportingdocumentationinadditiontotheholder’ssignature.
• Tickallboxeswhichapply.Seethereverseofthisformfordefinitionsandmoreinformation.
Area I
Holder
Part A
Transferfrom
aTFSA
Part B
Descriptionof
amounttobe
trans
f
erred
(Check one box only for asset transfer instructions and an additional box if asset list is attached)
Allincash* Partial*
* BysigninginthesignaturesectionofPartChereIhaverequestedatransferincash,Iauthorizetheliquidationofallorpartofmyinvestmentsasindicated.I
agreetopayanyapplicablefees,chargesoradjustmentsasperdisclosurerelatedtothistransfer.
listattached
Part C
Destinationof
Transfer
Pleasetransfertheabove-mentionedTFSApropertytotheTFSAofmyspouse.
See letter attached See order attached
Area II
Transferee/
ReceivingIssuer
Weagreetotherequestforatransferofproperty.
1.Whenwereceivetheproperty,wewillcreditittotheTFSAofthespouseidentiedinPartCofAreaI.TheTFSAconforms,orwillconform
totheTFSAidentiedas:
Part A
Transferee/
ReceivingIssuer
2.ThearrangementisregisteredundertheIncome Tax ActasaTFSA,or,ifthearrangementisnotregisteredasaTFSA,wewillapplyforsuch
registrationpursuanttotherequirementsundertheapplicablesection(s)oftheIncome Tax Act,whichgovern(s)TFSAregistrations.
Part B
Receivingspouse
See letter attached See order attached
Area III
Transferor/
DeliveringIssuer
1. Wetransferred$ fromtheTFSAidentiedinPartAofAreaItothetransfereenamedinPartCofAreaI,on
.
2. Themarketvalueofthepropertyintheholder’sTFSAjustbeforethetransferwas $
,or
seeattached.
3. Theinformationinthisareaistrue,correctandcomplete.
___________________ ____________________
_______________ ______________
Transfer from a Tax-Free Savings Account (TFSA) to another TFSA on breakdown of marriage or common-law
partnership (cont’d)
Page 2 of 2
Who should use this form and why?
ThisformisforusebyaTFSAholderorthetransferor,orforaTFSAholder’sspouseortransferee,torequestthetransferofanamountintheholder’s
TFSAtotheTFSAoftheholder’sspousewhere:
• thoseindividualsareorwerespouses;
• thetransferisrequiredaspartofthedivisionofpropertyinthesettlementoftheindividuals’rightswithrespecttothebreakdownofmarriageor
common-lawpartnership;and
• thetransferisinaccordancewiththetermsofavalidorder.
If you are the individual FROM whose TFSA an amount is to be transferred:
CompleteAreaIoftheformandtake,orsendtheformoryourwritteninstructions,tothetransferor(yourfinancialinstitution)oryour
financialadvisor.IfyoudonothavecompleteinformationabouttheTFSAtowhichtheamountistobetransferred,thetransferee(the
financialinstitutionofyourspouse)cancompletePartCofAreaI.
If you are the individual TO whose TFSA an amount is to be transferred:
Providethetransferor,throughyourfinancialinstitutionoryourfinancialadvisor,withthisformoryourwritteninstructions,includinga
copyoftheorderifrequested(youcanincludeacopyoftheordertothetransferorsealedinanenvelope).
Area I: TheholderwhorequeststhetransfercompletesandsignsAreaI.AtransferorwhocompletesAreaIfortheholdercanattach
writteninstructionsfromtheholderrequestingthedirecttransfer,inplaceofasignature.Ifthetransferordoesnothavecomplete
informationaboutthespouse’sTFSA,thetransfereecancompletePartCofAreaI.
Area II: ThetransfereecompletesandsignsAreaII,anditiscountersignedbythespouse.Thetransfereecanattachwritteninstructions
fromthespouseacknowledgingthecertification,inplaceofacountersignature.
Area III:ThetransferorcompletesandsignsAreaIII.
Are there any tax implications?
NoamounttransferredinaccordancewiththisformisreportedasaTFSAwithdrawaloracontributiontoaTFSAforincometaxpurposes,
nordoessuchatransferalterthepermittedTFSAcontributionsofeitherindividual.Donotissueataxreceiptfortaxpurposes.
Definitions
Holder:ThepersonwhoisentitledtoreceivedistributionsfromaTFSAasdefinedinsection146.2oftheIncome Tax Act.
Income Tax Act:The Income Tax Act(Canada).
Individual account number:Thenumericaloralphanumericidentifierassignedbytheissuertotheindividualaccount,contract,certificate,
annuity,depositorotherqualifiedinvestmentidentifiedinsubsection146.2(1)oftheIncome Tax Act,withwhomaholderhasacontractor
arrangementthattheissuerhasfiledwiththeMinisterofNationalRevenuetoregisterasaTFSA.
Issuer:Apersonofferingqualifyingarrangementswhoisauthorizedtoprovidetrusteeservices,annuitiescontractsordeposits,asdefinedin
subsection146.2(1)oftheIncome Tax Act.
Order:Adecree,orderorjudgementofacompetenttribunal,orawrittenseparationagreement.
Spouse:Aspouseorcommon-lawpartneroftheholderoraformerspouseorformercommon-lawpartneroftheholderasdefinedunder
theIncome Tax Act.
Tax-Free Savings Account (“TFSA”):AqualifyingarrangementregisteredwiththeMinisterofNationalRevenue.
Transferee:TheissueroftheTFSATOwhichthepropertyistransferred.
Transferor:TheissueroftheTFSAFROMwhichthepropertyistransferred.
Transferred amount:
All in cash:Theentireaccountincash,afterallassetsareredeemedorconvertedtocash.
Partial:Thespecifiedassetsinanaccount.
4378-E-07-09