Canada Revenue

Agency
Agence du revenu
du Canada Year T4A
Statement of Pension, Retirement, Annuity,
Payer's name and Other Income

Social insurance number Pension or superannuation – line 115

012 016
Recipient's number
Pension plan registration number Lump-sum payments – line 130
014
036 018

Other Information Income tax deducted – line 437

Recipient's name and address Box Amount 022

T4A (18) Protected B when completed

Box Amount Box Amount

Box Amount Box Amount

Box Amount Box Amount

Privacy Act, Personal Information Bank Number CRA PPU 005 and CRA PPU 150 and CRA PPU 125
ATTACH TO YOUR INCOME TAX RETURN 2
Canada Revenue
Agency
Agence du revenu
du Canada Year T4A
Statement of Pension, Retirement, Annuity,
Payer's name and Other Income

Social insurance number Pension or superannuation – line 115

012 016
Recipient's number

014 Pension plan registration number Lump-sum payments – line 130

036 018

Other Information Income tax deducted – line 437

Recipient's name and address Box Amount 022

T4A (18) Protected B when completed

Box Amount Box Amount

Box Amount Box Amount

Box Amount Box Amount

Privacy Act, Personal Information Bank Number CRA PPU 005 and CRA PPU 150 and CRA PPU 125
TO BE KEPT BY THE RECIPIENT (SEE INFORMATION BELOW) 3
For information on how to report your income, please refer to your tax guide.

Report these amounts on your tax return. Do not report on your tax return – Canada Revenue Agency use only

Box 016, Pension or superannuation – Enter this amount on line 115. It may Box 036, Plan registration number
qualify for the pension income amount (see line 314 in your tax guide). See line
Box 146, Status Indian (exempt income) – Pension or superannuation
115 and 130 in your tax guide.
Box 148, Status Indian (exempt income) – Lump-sum payments
Box 018, Lump-sum payments – Enter this amount on line 130.
The amounts in the following boxes are included in box 018: Do not report on your tax return – Pension Plan use only
• Box 108, Lump-sum payments from a registered pension plan (RPP) that you
cannot transfer. Box 014, Recipient number (Pension Plan Personal Identification Number)
• Box 190, Lump-sum payments from an unregistered plan

Box 022, Income tax deducted – Enter this amount on line 437.

Box 135, Recipient-paid premiums for private health plans – See line 330 in
your tax guide.

Enter on line 104:

• Box 118, Medical premium benefits
• Box 119, Premiums paid to a group term life insurance plan

Enter on line 130:

• Box 109, Periodic payments from an unregistered plan

PC 97-080 2019.11.09 RMS