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

Form

1040NR-EZ

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

Please print
or type.
See
separate
instructions.
Filing Status
Check only one box.

Attach
Form(s)
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
instructions.

Amount
You Owe

Third
Party
Designee

Sign
Here
Paid
Preparer
Use Only

2011
Identifying number (see instructions)

Last name

Present home address (number, street, and apt. no., or rural route). If you have a P.O. box, see instructions.
City, town or post office, state, and ZIP code. If you have a foreign address, see instructions.

Foreign country name

1

Single nonresident alien

Foreign province/county

2

Foreign postal code

Married nonresident alien

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18a
b
19
20
21
22
23a
b
d
e

Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . .
Taxable refunds, credits, or offsets of state and local income taxes . . . . . .
Scholarship and fellowship grants. Attach Form(s) 1042-S or required statement. .
Total income exempt by a treaty from page 2, Item J(1)(e) .
6
Add lines 3, 4, and 5 . . . . . . . . . . . . . . . . . . . . .
Scholarship and fellowship grants excluded . . . . .
8
Student loan interest deduction . . . . . . . . .
9
Subtract the sum of line 8 and line 9 from line 7. This is your adjusted gross income .
Itemized deductions . . . . . . . . . . . . . . . . . . . . .
Subtract line 11 from line 10 . . . . . . . . . . . . . . . . . . .
Exemption . . . . . . . . . . . . . . . . . . . . . . . . .
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 . . . . . . . .
Unreported social security and Medicare tax from Form: a 4137
b 8919
Add lines 15 and 16. This is your total tax . . . . . . . . . . . . . ▶
Federal income tax withheld from Form(s) W-2 and 1099-R
18a
Federal income tax withheld from Form(s) 1042-S . . .
18b
2011 estimated tax payments and amount applied from 2010 return
19
Credit for amount paid with Form 1040-C . . . . .
20
Add lines 18a through 20. These are your total payments . . . . . . . . ▶
If line 21 is more than line 17, subtract line 17 from line 21. This is the amount you overpaid
Amount of line 22 you want refunded to you. If Form 8888 is attached, check here ▶
Routing number
c Type: Checking
Savings
Account number
If you want your refund check mailed to an address outside the United States not
shown above, enter that address here:

24
25
26

Amount of line 22 you want applied to your 2012 estimated tax ▶
24
Amount you owe. Subtract line 21 from line 17. For details on how to pay, see instructions
Estimated tax penalty (see instructions) . . . . . . .
26

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

7

10
11
12
13
14
15
16
17

21
22
23a

25

Yes. Complete the following.

No

Personal identification
▶
number (PIN)

Phone
▶
no.

▶

▶

3
4
5

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.

OMB No. 1545-0074

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

Your signature

Print/Type preparer’s name

Firm’s name

▶

Firm's address

▶

Date

Preparer's signature

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

Your occupation in the United States
Date

Check
if
self-employed

PTIN

Firm's EIN ▶
Phone no.
Cat. No. 21534N

Form 1040NR-EZ (2011)

Page 2

Form 1040NR-EZ (2011)

Schedule OI- Other Information (see instructions)
Answer all questions
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, for expatriation rules that may apply to you.

.
.

.
.

Yes
Yes

No
No

E

If you had a visa on the last day of the tax year, enter your visa type. If you did not have a visa, enter your U.S. immigration
status on the last day of the tax year.

F

Have you ever changed your visa type (nonimmigrant status) or U.S. immigration status? .
If you answered “Yes,” indicate the date and nature of the change. ▶

G

List all dates you entered and left the United States during 2011 (see instructions).
Note. If you are a resident of Canada or Mexico AND commute to work in the United States at frequent
intervals, check the box for Canada or Mexico and skip to item H . . . . . . . . . . . .
Date entered United States
mm/dd/yy

H

I

J

.

.

Date entered United States
mm/dd/yy

Date departed United States
mm/dd/yy

.

.

.

.

Yes

Canada

No

Mexico

Date departed United States
mm/dd/yy

Give number of days (including vacation, nonworkdays, and partial days) you were present in the United States during:
2009
, 2010
, and 2011
Did you file a U.S. income tax return for any prior year?
If “Yes,” give the latest year and form number you filed

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Yes

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No

▶

Income Exempt from Tax—If you are claiming exemption from income tax under a U.S. income tax treaty with a foreign country,
complete (1) and (2) below. See Pub. 901 for more information on tax treaties.
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 instructions).
(a) Country

(b) Tax treaty
article

(d) Amount of exempt
income in current tax year

(c) Number of months
claimed in prior tax years

(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?

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Yes

No

Form 1040NR-EZ (2011)