8854 Initial and Annual Expatriation Information Statement

Form

8854

OMB No. 1545-0074

Initial and Annual Expatriation Information Statement
©

Department of the Treasury
Internal Revenue Service

©

See separate instructions.

©

2007

Please print or type.

Attachment
Sequence No.

Section references on this form are to the Internal Revenue Code.

Name

Date of birth (mo., day, yr.)

112

Tax Year

Initial or Annual Information Statement. Check the box that applies.
Initial Information Statement. Complete Parts I, II, and III, and Schedules A and B.
Annual Information Statement. Complete Parts I and III and Schedules A and B. Skip Part II (see instructions).

Part I

General Information. All filers must complete Part I. See instructions.
©

1

Identifying number (see instructions)

2

Mailing address and telephone number where you can be reached after expatriation

3

Address of principal foreign residence (if different from line 2)

4

Country of tax residence (if different from line 3)

5

Date of notification of expatriating act, termination of residency, or claim of treaty benefits. Check the box that applies
and enter the appropriate date.

a

Citizen. Date notification given to Department of State

b

Long-term resident. Date notification given to Homeland Security

c

Long-term resident with dual residency in a treaty country. Date commencing to be treated, for tax purposes, as a
resident of the treaty country
.

Part II
6

(see instructions).
(see instructions).

Initial Expatriation or Termination Information Statement

Enter your U.S. income tax liability (after foreign tax credits) for the 5 tax years ending before the date of expatriation.
1st Year
Before Expatriation
$

2nd Year
Before Expatriation
$

3rd Year
Before Expatriation
$

4th Year
Before Expatriation
$

5th Year
Before Expatriation
$

$

7

Enter your net worth on the date of your expatriation for tax purposes

8

Did you become at birth a U.S. citizen and a citizen of another country, and do you continue to be
a citizen of that other country?

Yes

No

Do you have substantial contacts with the United States? (See instructions.)

Yes

No

10

Are you a minor described in section 877(c)(3)? (See instructions.)

Yes

No

11

Do you certify under penalty of perjury that you have complied with all of your tax obligations for
the 5 preceding tax years? (See instructions.)

9

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 24126N

Yes
Form

No

8854

(2007)

Form 8854 (2007)

Part III

Page

2

Annual Information Reporting under Section 6039G

Do not complete this part if:
● Your average annual net income tax liability for years 1-5 (line 6) was not more than the limit listed under Taxation Under
Section 877 on page 1 of the instructions and your net worth on line 7 was under $2,000,000, and you checked “Yes” to
line 11, or
● You checked “Yes” to line 8 and “No” to line 9, and you checked “Yes” to line 11, or
● You checked “Yes” to line 10, and you checked “Yes” to line 11.

12

List all countries (other than the United States) of which you are a citizen.

a Name of country
b How you became a citizen
c Date you became a citizen
13 Number of days you were physically present in the United States during the current year. If you were
present in the United States more than 60 days, skip line 14
14

Were you physically present in the United States for more than 30 days but not more than 60 days
during the tax year?

Yes

No

a Were you performing services for an unrelated employer?

Yes

No

b If you checked “Yes” to line 14a, are you a citizen or resident, fully liable for income tax, in the
country in which you were born, your spouse was born, or either of your parents were born?

Yes

No

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best
of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than filer) is based on all information of which
preparer has any knowledge.

Sign
Here

Your signature

Date

Preparer’s signature

Date

Form

8854

(2007)

Form 8854 (2007)

Page

3

Schedule A Balance Sheet
● If this is an initial information statement, list in U.S. dollars the fair market value (column (a)) and the U.S. adjusted basis (column
(b)) of your assets and liabilities as of the date of your expatriation for tax purposes.
● If this is an annual information statement, list in U.S. dollars the fair market value (column (a)) and the U.S. adjusted basis
(column (b)) of your assets and liabilities as of the end of the tax year for which you are filing this form.
● If you are a former U.S. long-term resident (LTR), it may benefit you to complete column (d). Only former LTRs should do so.

For more details, see the separate instructions.
Assets
1
2
3
4
5

(a) Fair Market
Value (FMV)

(b) U.S. adjusted
basis

(c) Gain or (Loss).
Subtract column (b)
from column (a)

(d) FMV on beginning
date of U.S. residency
(optional, for LTRs only)

Cash, including bank deposits
Marketable stock and securities issued by
U.S. companies
Marketable stock and securities issued by
foreign companies
Nonmarketable stock and securities issued by
U.S. companies
Nonmarketable stock and securities issued by
foreign companies
a Separately state stock issued by foreign
companies that would be controlled foreign
corporations if you were still a U.S. citizen or
permanent resident (see instructions)
b Provide the name, address, and EIN, if any, of
any such company

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

21
22
23
24
25

Pensions from services performed in the
United States
Pensions from services performed outside
the United States
Partnership interests (see instructions)
Assets held by trusts you own under
sections 671–679 (see instructions)
Beneficial interests in nongrantor trusts
(see instructions)
Intangibles used in the United States
Intangibles used outside the United States
Loans to U.S. persons
Loans to foreign persons
Real property located in the United States
Real property located outside the United
States
Business property located in the United
States
Business property located outside the
United States
Other assets (see instructions)
Total assets. Add lines 1 through 5 and lines
6 through 19. Do not include amounts on line
5a in this total
Liabilities

Amount

Installment obligations
Mortgages, etc.
Other liabilities (see instructions)
Total liabilities. Add lines 21 through 23
Net worth. Subtract line 24 from line 20,
column (a)
Form

8854

(2007)

Form 8854 (2007)

Schedule B

Page

4

Income Statement

● If this is an initial information statement, provide income information for that portion of the year that ends on the
date of your expatriation for tax purposes.
● If this is an annual information statement, provide income information for the tax year for which you are filing the
form.
1

U.S. source gross income not effectively connected with the conduct of a U.S. trade or business.
a Interest

1a

b Dividends

1b

c Royalties

1c

d Pension distributions

1d

e Other
f Total. Add lines a through e

1e
1f

2

Gross income that is effectively connected with the conduct of a U.S. trade or business

2

3

Income from the performance of services in the United States

3

4

5

Gains from the sale or exchange of:
a Property (other than stock or debt obligations) located in the
United States
b Stock issued by a U.S. domestic corporation
c Debt obligations of U.S. persons or of the United States, a state or
political subdivision thereof, or the District of Columbia
d Total. Add lines a through c

4a
4b
4c
4d

Income or gain derived from certain foreign corporations to the extent of your share of earnings
and profits earned or accumulated before the date of expatriation (see instructions)

5

6

Gains on certain exchanges of property that would ordinarily not be recognized (see instructions)

6

7

Income received or accrued by certain foreign corporations (see instructions)

7

8

Add lines 1f, 2, 3, 4d, 5, 6, and 7

8

9

Gross income from all other sources

9

Total. Add lines 8 and 9

10

10

Form

8854

(2007)