Roth IRA Election Letter

Date: Month, Day, Year

To:	Competent Authority Services Division
	International and Large Business Directorate
	5th Floor, Canada Building
	344 Slater Street
	Ottawa, ON K1A 0L5

Name and address: Trump Refugee, 123 Street Name, City, Province, Postal Code
Social insurance number: xxx-xxx-xxx

Social security number: xxx-xx-xxxx
Date I became resident in Canada: Month, Day, Year

I elect to defer Canadian taxation under paragraph 7 of Article XVIII of the Canada-U.S. Income Tax Convention with respect to any income accrued in my Roth IRAs listed below for all taxation years until such time as a Canadian Contribution is made:

Name and address of Roth IRA trustee or custodian:

Firm 1 Name, Address, City, State, Zip, USA
Roth IRA account number: xxxxxxxx
Date plan was established:  Month, Day, Year
Balance in Canadian $ of the Roth IRA as of the date I became resident in Canada: $xxxxxx
Amount and date of the first Canadian Contribution made to the Roth IRA: none

Name and address of Roth IRA trustee or custodian:

Firm 2 Name, Address, City, State, Zip, USA
Roth IRA account number: xxxxxxxx
Date plan was established:  Month, Day, Year
Balance in Canadian $ of the Roth IRA as of the date I became resident in Canada: $xxxxxx
Amount and date of the first Canadian Contribution made to the Roth IRA: none



Trump Refugee