Form 1040 NR-EZ U.S. Income Tax Return for Certain Nonresident Aliens wi

Form

1040NR-EZ

OMB No. 1545-0074

U.S. Income Tax Return for Certain
Nonresident Aliens With No Dependents

2009

Department of the Treasury
Internal Revenue Service
Your first name and initial

Please
print or
type.

Last name

Identifying number (see page 4)

Present home address (number, street, and apt. no., or rural route). If you have a P.O. box, see page 4.

City, town or post office, state, and ZIP code. If you have a foreign address, see page 4.

Country 䊳

Filing Status
Check only one box.

Attach
Forms
W-2 or
1042-S
here.
Also
attach
Form(s)
1099-R if
tax was
withheld.

Enclose,
but do not
attach, any
payment.

Refund
Direct
deposit? See
page 8 and
fill in 23b,
23c, and
23d, or
Form 8888.

1
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

Single nonresident alien

2

Married nonresident alien

Wages, salaries, tips, etc. Attach Form(s) W-2 (see pages 4 and 5)
Taxable refunds, credits, or offsets of state and local income taxes (see page 5)
Scholarship and fellowship grants. Attach Form(s) 1042-S or required statement (see page 5)
6
Total income exempt by a treaty from page 2, Item J(1)(e)

3
4
5

Add lines 3, 4, and 5
8
Scholarship and fellowship grants excluded (see page 6)
9
Student loan interest deduction (see page 6)
Subtract the sum of line 8 and line 9 from line 7. This is your adjusted gross income
Itemized deductions (see page 7)
Subtract line 11 from line 10
Exemption (see page 7)
Taxable income. Subtract line 13 from line 12. If line 13 is more than line 12, enter -0Tax. Find your tax in the Tax Table on pages 17 through 25
4137 b
8919
Unreported social security and Medicare tax from Form: a
䊳
Add lines 15 and 16. This is your total tax
18
Federal income tax withheld (from Forms W-2, 1042-S, and 1099-R)
19
2009 estimated tax payments and amount applied from 2008 return
20
Credit for amount paid with Form 1040-C
䊳
Add lines 18 through 20. These are your total payments

7

22 If line 21 is more than line 17, subtract line 17 from line 21. This is the amount you overpaid
23a Amount of line 22 you want refunded to you.
䊳
If Form 8888 is attached, check here
c
Type:
Checking
Savings
b Routing number

10
11
12
13
14
15
16
17

21
22
23a

d Account number
e If you want your refund check mailed to an address outside the United States not
shown above, enter that address here:

䊳

24 Amount of line 22 you want applied to your 2010 estimated tax

24

Amount
You Owe

25 Amount you owe. Subtract line 21 from line 17. For details on how to pay, see page 9
26 Estimated tax penalty (see page 9). Also include on line 25 26

Third
Party
Designee

Do you want to allow another person to discuss this return with the IRS (see page 10)?
Designee’s
䊳
name

Phone
䊳
no.

(

)

䊳

25

Yes. Complete the following.

No

Personal identification
䊳
number (PIN)

Sign
Here

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 accurately list all amounts and sources of U.S. source income I received during the tax year. Declaration of
preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Keep a copy of
this return for
your records.

䊳

Paid
Preparer’s
Use Only

Preparer’s
signature

Date

Your signature

䊳

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

Date

䊳

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 15.

Your occupation in the United States

Check if
self-employed

Preparer’s SSN or PTIN

EIN
Phone no.
Cat. No. 21534N

(
Form

)

1040NR-EZ

(2009)

Form 1040NR-EZ (2009)

Page

2

Other Information (see page 10)
A Of what country or countries were you a citizen or national during the tax year?
B In what country did you claim residence for tax purposes during the tax year?
C Have you ever applied to be a green card holder (lawful permanent resident) of the United States?

Yes

No

D Were you ever:
1. A U.S. citizen?
2. A green card holder (lawful permanent resident) of the United States?
If you answer “Yes” to 1 or 2, see Pub. 519, chapter 4, to see expatriation rules that apply to you.

Yes
Yes

No
No

Yes

No

E What was your visa type on the last day of the tax year?
F

Have you ever changed your visa type (nonimmigrant status)?

G List all dates you entered and left the United States during 2009 (see page 10).
Note. If you are a resident of Canada or Mexico AND enter and leave the United States at frequent
intervals, check the box for Canada or Mexico and skip to question H
Date entered United States Date departed United States
mm/dd/yy
mm/dd/yy

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Canada

Mexico

Date entered United States Date departed United States
mm/dd/yy
mm/dd/yy

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H Give number of days (including vacation, nonworkdays, and partial days) you were present in the United States during
2007
, 2008
, and 2009
.
I

Did you file a U.S. income tax return for any prior year?
If “Yes,” give the latest year and form number you filed 䊳

J

Income Exempt from Tax—If you are claiming the benefits of a U.S. income tax treaty with a foreign country, complete 1
and 2 below. See Pub. 901 for more information on tax treaties.

Yes

No

1. Enter the name of the country, the applicable tax treaty article, the number of months in prior years you claimed the
treaty benefit, and the amount of exempt income in the columns below. Attach Form 8833 if required (see page 10).
(a) Country

(b) Tax treaty
article

(c) Number of months
claimed in prior tax years

(d) Amount of exempt
income in current tax year

(e) Total. Enter this amount on Form 1040NR-EZ, line 6. Do not enter it on line 3 or line 5
2. Were you subject to tax in a foreign country on any of the income shown in 1(d) above?

Yes
Form

1040NR-EZ

No
(2009)