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Flag Canada Revenue
Agency		 Agence du revenu
du Canada		 Protected B when completed
  For departmental use.
Foreign Income Verification Statement  
   
• This form must be used for the 2015 and later taxation years.  
• Complete and file this form if at any time in the year the total cost amount to the reporting taxpayer
of all specified foreign property was more than $100,000 (Canadian).		  
• If an election has been made to use a functional currency (see attached instructions), state the
elected functional currency code. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		    
• See attached instructions for more information about completing this form.  
 
If this is an amended return, tick this box.
 
Identification
 
Tick a box to indicate who you are reporting for, and complete the areas that apply.
   First name  Last name  Initial  Social insurance number  Individual code
 
Individual
  
1
2
   Corporation's name  Business number
 
Corporation
  
   Trust's name  Account number
 
Trust
   T
     Partnership's name  Partnership code  Partnership's account number
  Partnership  
1
2
3
 Reporting entity's address
 
     
  No.   Street  
 
         
  City   Province or territory Postal code Country code
 
  Year Month Day   Year Month Day  
 For what taxation year are you filing this form? From to  
 
 
 Tick the appropriate box that applies for the taxation year:
If the total cost of all specified foreign property held at any time during the year exceeds $100,000 but was less than $250,000, you are required to
complete either Part A or Part B;
If the total cost of all specified foreign property held at any time during the year was $250,000 or more, you are required to complete Part B.
 
  Tick the appropriate box to select the method of filing; Part A – Simplified reporting method or Part B – Detailed reporting method 
 
Part A: Simplified reporting method
 For each type of property that applies to you, tick the appropriate box.
 Type of property:
 
  Funds held outside Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 
  Shares of non-resident corporations (other than foreign affiliates) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 
  Indebtedness owed by non-resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 
  Interests in non-resident trusts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 
  Real property outside Canada (other than personal use and real estate used in an active business) . . . . . . .
 
  Other property outside Canada. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 
  Property held in an account with a Canadian registered securities dealer or a Canadian trust company. . . . .
 
 Country code:
 Select the top three countries based on the maximum cost amount of specified foreign property held during the year. Enter the country codes in the boxes below:
 
       
 
 Gross income from all specified foreign property $  
 Gain(loss) from the disposition from all specified foreign property $  
 
 Privacy Act, personal information bank number CRA PPU 035
 
T1135 E (23) (Ce formulaire est disponible en français.) Canada Logo