Form 1040-C U.S. Departing Alien Income Tax Return

2
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Date

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 1040C, PAGE 1 of 4
PRINTS: HEAD to FOOT
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 203mm (8") 3 559mm (22"), FOLD TO: 203mm (8") 3 279mm (11")
PERFORATE: ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form

1040-C

For tax period or year beginning
© See separate instructions.

Signature

O.K. to print
Revised proofs
requested

, 2009, and ending
© File original and one copy.

OMB No. 1545-0086

2009

,

Your first name and initial

Last name

Your identifying number

If a joint return, spouse’s first name and initial (see instructions)

Last name

Spouse’s identifying number

U.S. address (number, street, and apt. no. or rural route)

Passport or alien registration card number
Your number

Original date of your entry into the U.S.

Spouse’s number

City, state, and ZIP code

Date of departure

Complete foreign address

Date on which you last arrived in the U.S.

Of what country are you a citizen or subject?

D

Date

U.S. Departing Alien Income Tax Return

Department of the Treasury
Internal Revenue Service

Print or type

Action

Of what country are you a resident?

Caution: Form 1040-C is not a final income tax return. You must file a final return on the correct form after your tax year ends.
See Final Return Required on page 2 of the instructions.

Part I
1

2
3
4
5

Explanation of Status—Resident or Nonresident Alien

Check the applicable box or boxes. Note: A nonresident alien who has income from U.S. real property may elect to treat this
income as effectively connected income. Gain or loss on the disposition of a U.S. real property interest by a nonresident alien is
effectively connected income or loss. For details, see the 2008 Form 1040NR instructions or Pub. 519, U.S. Tax Guide for Aliens.
Group I—Resident alien.
Group II—Nonresident alien with income effectively connected with a U.S. trade or business.
Group III—Nonresident alien with income not effectively connected with a U.S. trade or business.
Type of trade or business or occupation in the United States ©
Visa number and class under which you were last admitted to the United States ©
Do you have a permit to reenter the United States?
If “Yes,” enter the expiration date ©
Have you signed a waiver of rights, privileges, exemptions, and immunities as described under Exceptions
on page 2 of the instructions?
If “Yes,” enter the date signed ©

During your stay in the United States did you furnish either of the following forms to a withholding agent:
Form W-9, Request for Taxpayer Identification Number and Certification, or Form 1078, Certificate of Alien
Claiming Residence in the United States?
7a Have you applied for U.S. citizenship?

Yes

No

Yes

No

Yes
Yes

No
No

6

b Have you applied for, or taken other affirmative steps to apply for, lawful permanent resident status in the
United States, or do you have an application pending to change your status to that of a lawful permanent
Yes
No
resident of the United States?
8 If you filed income tax returns in the United States, give the following information for 2008:
a Type of return filed (for example, Form 1040, 1040NR, etc.) ©
b Your U.S. address shown on return ©
d Tax paid $
c Taxable income reported $
e Balance due $
9 Do you know of any current charges against you concerning your U.S. taxes for any tax period?
Yes
No
10 Do you plan to return to the United States?
Yes
No
If “Yes,” complete lines 11 through 13 below.
11 Are your spouse and any children remaining in the United States?
Yes
No
12 Show the approximate value and location in the United States of any property held by you:
Value
Location
$
;
a Real property
$
;
$
;
b Stocks and bonds
$
;
c Cash
$
;
d Other (specify) ©
13 If you will not return before the due date for filing a final U.S. income tax return for the current year or the due date for filing
a final U.S. income tax return for the preceding year, what arrangements have you made to file the final income tax return(s)
and pay the tax(es)? ©

$

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 7 of instructions.

Cat. No. 11310F

Form

1040-C

(2009)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 1040C, PAGE 2 of 4
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to FOOT
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 203mm (8") 3 559mm (22"), FOLD TO: 203mm (8") 3 279mm (11")
PERFORATE: ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 1040-C (2009)

Page

2

Exemptions

Part II

Group I — If you are a resident alien, you may claim the same exemptions allowed U.S. citizens on Form 1040.
Group II — If you are a nonresident alien with income effectively connected with a U.S. business, you may claim one exemption. Residents of Canada,
India, Mexico, or the Republic of Korea (South Korea), or U.S. nationals, see page 4 of the instructions.
Group III — If you are a nonresident alien with income not effectively connected with a U.S. business, do not claim any exemptions for that income.
Yourself

14a

b

Spouse

Caution: If your parent (or someone else) can claim you as a dependent on his or her 2009 tax return,
do not check box 14a.
c Dependents:
(1) First name

(3) Dependent’s
relationship
to you

(2) Dependent’s
SSN or ITIN

Last name

(4) if qualifying
child for child tax
credit

No. of boxes checked
on 14a and 14b . . .
No. of your children
on 14c who:
● lived with you .
● did not live with
you due to divorce
or separation . .
Dependents on 14c
not entered above
Add numbers entered
©
on lines above

d Total number of exemptions claimed

Figuring Your Income Tax

Tax Summary

Group III

Groups I and II

Part III
15
16
17
18
19
20
21
22

Total income (from page 3, Schedule A, line 4, column (d) or (e))
Adjustments. See page 4 of the instructions and attach appropriate form or statement
Adjusted gross income. Subtract line 16 from line 15
Enter the amount from page 4, Schedule D, line 8 or 16, whichever applies
Credits. See page 4 of the instructions and attach appropriate form or statement
Subtract line 19 from line 18. If zero or less, enter -0Other taxes. See page 4 of the instructions and attach appropriate form
Tax for Group I or II. Add lines 20 and 21

23
23 Total income (from page 3, Schedule A, line 4, column (f))
24 Tax (30% of line 23). If less than 30%, attach statement showing computation
©
25 Total tax. Add lines 22 and 24
Note: Your tax liability on your final return may be different from line 25.
26 U.S. income tax paid or withheld at source (from page 3, Schedule A,
26
lines 4 and 5, column (c))
27
27 Estimated U.S. income tax paid
28
28 Other payments (specify) ©
©
29 Total payments. Add lines 26 through 28
30 If line 25 is more than line 29, subtract line 29 from line 25. This is the amount you owe
31 If line 29 is more than line 25, subtract line 25 from line 29. This is the amount you overpaid.
Any overpayment of tax will be refunded only when you file your final return for the tax year

Sign
Here
Keep a copy
of this return
for your
records.

Paid
Preparer’s
Use Only

©

15
16
17
18
19
20
21
22

24
25

29
30
31

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge
and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any
knowledge.
Your signature

Date

(A return made by an agent must be accompanied by a power of attorney.)
Preparer’s
signature

©

©

Date
Spouse’s signature
(If filing jointly, both must sign even if only one had income.)
Preparer’s SSN or PTIN

Date

Firm’s name (or yours
if self-employed),
address, and ZIP code

Check if
self-employed

©

EIN
Phone no.

(

)

Certificate of Compliance
This certifies that the above individual(s) has satisfied all the requirements of the Internal Revenue Code and the Internal Revenue Regulations relating to departing
aliens according to all information available to me at this date. This certificate is effective for the tax period
beginning

, 2009, and ending

,

, or the tax year ended

,

.

(Field Assistance Area Director)
Internal Revenue Service
Date

,

By
(Name)

(Title)
Form

1040-C

(2009)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 1040C, PAGE 3 of 4
PRINTS: HEAD to FOOT
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 203mm (8") 3 559mm (22"), FOLD TO: 203mm (8") 3 279mm (11")
PERFORATE: ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 1040-C (2009)

Schedule A
1

2
3
4
5

2

(b) Type of income (such as
salary, wages, taxable
interest, dividends, rents,
alimony received, etc.)

Net gain, if any, from Schedule D (Form 1040)
Net gain, if any, from Schedule B, line 2
Totals
Exempt income. Do not include on line 4

(c) Amount of U.S.
income tax paid or
withheld at source

Nonresident alien income
(d) Resident alien
income

(e) Effectively
(f) Not effectively
connected with a U.S. connected with a U.S.
trade or business
trade or business

2
3
4
5

Certain Gains and Losses From Sales or Exchanges of Nonresidents’ Property Not Effectively
Connected With a U.S. Trade or Business (see instructions). Include any U.S. income tax that was
paid or withheld on these sales or exchanges on Schedule A, line 3, column (c).

(a) Description of property
(If necessary, attach statement of
descriptive details not shown below.)

(b) Date acquired
(mo., day, yr.)

(c) Date sold
(mo., day, yr.)

(d) Sales price

(e) Cost or other
basis

Net gain. Combine the gains and losses entered on line 1, column (f). If the total is greater than zero,
enter this net gain amount on Schedule A, line 3, column (f)

Schedule C

3

Income (see instructions)

(a) Payer of income

Schedule B
1

Page

(f) Gain or (loss)
subtract (e) from (d)

2

Itemized Deductions

● If you are a resident alien reporting income on Schedule A, column (d), you may claim the same deductions allowable on Schedule
A (Form 1040).
● If you are a nonresident alien reporting income on Schedule A, column (e), you may claim only deductions that are connected
to U.S. trade or business income and not deducted elsewhere. See Schedule A (Form 1040NR). However, casualty or theft
losses and charitable contributions do not have to be related to U.S. trade or business income. You should file Form 4684,
Casualties and Thefts, to support casualty or theft losses shown below.
● If you are a nonresident alien reporting income on Schedule A, column (f), do not claim any deductions related to that income.
1

2

(a) Type of deduction
(such as interest, taxes, contributions, etc.)

(b) Amount
of deduction

(c) Type of deduction
(such as interest, taxes, contributions, etc.)

Total itemized deductions. Add the amounts in columns (b) and (d) of line 1. Enter the total here
and on Schedule D, line 2 or line 10, whichever applies. Exception. If the amount on Form 1040-C,
line 17, is over $166,800 ($83,400 if married filing separately), see the instructions on page 6 for
the amount to enter

(d) Amount of
deduction

2
Form

1040-C

(2009)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 1040C, PAGE 4 of 4
PRINTS: HEAD to FOOT
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 203mm (8") 3 559mm (22"), FOLD TO: 203mm (8") 3 279mm (11")
PERFORATE: ON FOLD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 1040-C (2009)

Schedule D

Page

4

Tax Computation

Tax for Resident Alien—Group I Only (For description of groups, see line 1 on page 1.)

1

Enter amount from line 17 on page 2

1

2

If you itemize deductions, enter amount from page 3, Schedule C, line 2 (to the extent they are
allowable on Schedule A (Form 1040)). If you do not plan to itemize deductions, enter your standard
deduction. See Standard Deduction (Group I only) on page 7 of the instructions

2

3

Subtract line 2 from line 1

3

4

Exemptions. If line 1 above is $125,100 or less, multiply $3,650 by the total number of exemptions
claimed on line 14d on page 2. If line 1 above is over $125,100, or you provided housing to a
Midwestern displaced individual, see the instructions on page 7 for the amount to enter

4

5
6

Taxable income. Subtract line 4 from line 3
Tax. Figure your tax on the amount on line 5 by using the 2009 Tax Rate Schedules on page 8
of the instructions. Include in the total any tax from Form 4972 and Form 8814. Enter the tax
here

5

9
6

D
7

Alternative minimum tax (AMT). Enter the amount, if any, of AMT from Form 6251

8

Add lines 6 and 7. Enter the result here and on Form 1040-C, line 18

7
©

8

Tax for Nonresident Alien With Income Effectively Connected With a U.S. Trade or Business—Group II Only

Enter amount from line 17 on page 2

9

Enter itemized deductions from page 3, Schedule C, line 2 (to the extent they are allowable on
Schedule A (Form 1040NR))

10

11

Subtract line 10 from line 9

11

12

Exemptions. If line 9 above is $125,100 or less, multiply $3,650 by the total number of exemptions
claimed on line 14d on page 2. If line 9 above is over $125,100, or you provided housing to a
Midwestern displaced individual, see the instructions on page 7 for the amount to enter

12

13

Taxable income. Subtract line 12 from line 11

13

14

15

Tax. Figure your tax on the amount on line 13 by using the 2009 Tax Rate Schedules on page 8
of the instructions. Include in the total any tax from Form 4972 and Form 8814. Enter the tax
here
Alternative minimum tax (AMT). Enter the amount, if any, of AMT from Form 6251 D

16

Add lines 14 and 15. Enter the result here and on Form 1040-C, line 18

9
10

©

9
14
15
16
Form

Printed on recycled paper

1040-C

(2009)