Form 2063 U.S. Departing Alien Income Tax Statement

Form 2063
(Rev. June 2011)
Department of the Treasury
Internal Revenue Service

U.S. Departing Alien Income Tax Statement

Annual Certificate of Compliance

For a Resident Alien Against Whom a Termination Assessment Has Not Been Made or
For a Nonresident Alien Having No Taxable Income From United States Sources

1 Name (please print or type)

Social security number or ITIN, if any

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

City

(IRS Form 2063)

OMB No. 1545-0138

State and ZIP code

3 Complete foreign address

This certifies that
has satisfied all United States of America income tax obligations with respect to income received or to be received for
,
,
the tax year ended
determined to the extent practicable, based on all information
available to me on this date.

(Field Assistance Area Director)
Internal Revenue Service
4 Tax year

5 While in the U.S., check if you were:

6 Of what country are you a citizen or subject?

An employee
Self-employed
8 Date of departure

Yes

By
(Name and title)

9 Original date of your entry into the U.S.

11 Are you a resident alien
of the U.S.?

7 Passport or alien registration
card number

No

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

If “No,” enter the country of which you are a resident

▶

Area Director’s Stamp
For Privacy Act and Paperwork Reduction Act Notice, see back of form.

Cat. No. 21420Y

12a

Did you receive or do you expect to receive any income subject to U.S. income tax for the year shown on line
4 on the front of this form? . . . . . . . . . . . . . . . . . . . . . . . . .

IMPORTANT
Yes

No

If “Yes”:
b

Was U.S. income tax withheld?

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c

Did you make any estimated income tax payments?

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Yes
Yes

No
No

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Yes

No

b

Did you receive any income subject to U.S. income tax during the prior tax year? .
If “Yes,” give the following information:
U.S. address shown on the income tax return you filed for that year:

c

(1) Year

13a

14

.

.

(2) Taxable income

.

.

.

(3) Tax paid

(4) Balance due

Are you liable for filing tax returns or paying taxes to the United States for any prior year not shown above? .

Yes

No

Declaration. Under penalties of perjury, I declare that I have examined the above statements, and to the best of my knowledge and belief, they are true,
correct, and complete.

▲

Sign
Here

Signature of departing alien

Date

Please keep this certificate
with your passport

Privacy Act and Paperwork Reduction Act Notice. We ask for the
information on this form to carry out the Internal Revenue laws of the United
States. Internal Revenue Code sections 6001, 6011, 6012(a), 6851, and
their regulations require that you give us the information. Routine uses of
this information include giving it to the Department of Justice for civil and
criminal litigation and to cities, states, and the District of Columbia to carry
out their tax laws. We may also disclose this information to other countries
under a tax treaty, to federal and state agencies to enforce federal nontax
criminal laws, or to federal law enforcement and intelligence agencies to
combat terrorism. If you do not give the information asked for, you may be
charged penalties and you may be subject to criminal prosecution.
You are not required to provide the information requested on a form that
is subject to the Paperwork Reduction Act unless the form displays a valid
OMB control number. Books or records relating to a form or its instructions
must be retained as long as their contents may become material in the
administration of any Internal Revenue law. Generally, tax returns and
return information are confidential, as required by Code section 6103.
The time needed to complete and file this form will vary depending on individual
circumstances. The estimated average time is: Recordkeeping, 6 min.; Learning
about the law or the form, 3 min.; Preparing the form, 26 min.; Copying,
assembling, and sending the form to the IRS, 13 min. If you have comments
concerning the accuracy of these time estimates or suggestions for making this
form simpler, we would be happy to hear from you. You can email us at
*[email protected]. (The asterisk must be included in the address.) Please put
“Forms Comment” on the subject line. Or you can write to the Internal Revenue
Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111
Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send the form to
this address.