Form 8854 Initial and Annual Expatriation Information Statement

Form

8854

For calendar year 2012 or other tax year beginning

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

Initial and Annual Expatriation Statement

▶

, 2012, and ending

, 20

Information about Form 8854 and its separate instructions is at www.irs.gov/form8854.
▶ Please print or type.

Name

2012

Attachment
Sequence No. 112

Identifying number (see instructions)

Part I

General Information. For all filers.

1

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

2

Address of principal foreign residence (if different from line 1)

3

Country of tax residence (if different from line 2)

4

Expatriation date. Check the box that applies (see instructions).
June 4, 2004 – June 16, 2008. Complete Parts II and V
June 17, 2008 – December 31, 2011. Complete Part III if:
• You made an election to defer the payment of tax on a prior year Form 8854,
• You have an item of eligible deferred compensation, or
• You have an interest in a nongrantor trust.
Otherwise, you do not need to file Form 8854.
January 1, 2012 – December 31, 2012. Complete Parts IV and V

5

Date of notification of expatriating act, termination of residency, or claim of treaty benefits (see instructions).
Citizen. Date notification given to Department of State
Long-term resident. Date notification given to Department of Homeland Security
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

6

Number of days you were physically present in the United States in the current year

7

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

Name of country

b Date you became a citizen of each country listed in line 7a
8

How you became a U.S. citizen

1

Did you complete Form 8854 for any period after June 3, 2004, and before June 17, 2008?
No. STOP. You must complete Form 8854 for the year in which you expatriated for immigration purposes before filing
this form (see instructions).

Part II

By birth

Yes. Tax year for which Form 8854 first filed
2

a

By naturalization

For Persons Who Expatriated After June 3, 2004, and Before June 17, 2008

. Go to line 2.

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

If you checked “Yes” to line 2, were you performing services for an unrelated employer?

Yes

No

Yes

No

.

.

.

.

b If you checked “Yes” to line 2a, 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 was born? . . . . . . .
Next: Go to Part V.
For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 24126N

Form 8854 (2012)

Form 8854 (2012)

Part III

Page

2

For Persons Who Expatriated After June 16, 2008, and Before January 1, 2012

• If you made an election to defer the payment of tax, complete line 1.
• If you have an item of eligible deferred compensation, complete line 2.
• If you have an interest in a nongrantor trust, complete line 3.
1

Complete columns (a), (b), and (c) for all property on which you deferred tax on a prior year Form 8854. Complete column (d)
for any property you disposed of in 2012 and see the instructions for Part III.
(a)
Description of property

(b)
Amount of mark-to-market gain or
(loss) reported on prior year
Form 8854

(c)
Amount of tax deferred on prior year
Form 8854

(d)
Date of disposition (if any)

2

Did you receive any distributions of eligible deferred compensation items for 2012?
If “Yes,” Amount of distribution:
Amount withheld at source, if any:

Yes

No

3

Did you receive any distributions from a nongrantor trust for 2012?
If “Yes,” Amount of distribution:
Amount withheld at source, if any:

Yes

No

Part IV

For Persons Who Expatriated During 2012

Section A
Expatriation Information
1
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

$

$

2

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

3

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

Yes

No

If you answered “Yes” to question 3, have you been a resident of the United States for not more than 10 of
the last 15 tax years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

No

Were you under age 181/2 on the date you expatriated and have you been a U.S. resident for not more than
10 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

No

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

Yes

No

4

5

6

.

.

.

.

.

.

.

.

.

$

Form 8854 (2012)

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Form 8854 (2012)

Section B
Property Owned on Date of Expatriation
Do not complete Section B if:
• Your average net income tax liability for the 5 tax years immediately before expatriation (see line 1 in Section A) was not
more than $151,000, your net worth (see line 2 in Section A) was under $2 million, and you checked “Yes” on line 6 in
Section A;
• In Section A, you checked “Yes” on lines 3, 4, and 6; or
• In Section A, you checked “Yes” on lines 5 and 6.
7a

Do you have any eligible deferred compensation items? Checking the “Yes” box is an irrevocable waiver
of any right to claim any reduction in withholding for such eligible deferred compensation item under any
treaty with the United States . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

No

b Do you have any ineligible deferred compensation items? If “Yes,” you must include in income the
present value of your account on the day before your expatriation date . . . . . . . . . . . .

Yes

No

Do you have any specified tax deferred accounts? If “Yes,” you must include in income the entire
account balance on the day before your expatriation date . . . . . . . . . . . . . . . . .

Yes

No

d Do you have an interest in a nongrantor trust? Checking the “Yes” box is a waiver of any right to claim
any reduction in withholding on any distribution from such trust under any treaty with the United States
unless you make the election below . . . . . . . . . . . . . . . . . . . . . . . .

Yes

No

c

Check this box to elect under section 877A(f)(4)(B) to be treated as having received the value of your entire interest in the
trust (as determined for purposes of section 877A) as of the day before your expatriation date. Attach a copy of your
valuation letter ruling issued by the IRS (see instructions).
8

Recognition of gain or loss on the deemed sale of mark-to-market property. Caution. Do not include in column (a) any property
described on line 7a, 7b, 7c, or 7d.

Complete column (g) only if you are deferring tax on gain from any property listed in column (a).
(a)
Description of property

(b)
Fair market value
on day before date
of expatriation

(c)
Cost or other
basis*

(d)
Gain or (loss).
Subtract (c)
from (b)

(e)
Gain after
allocation of the
exclusion amount
(see instructions)

(f)
Form or Schedule
on which gain
or loss is reported

(g)
Amount of tax
deferred (attach
computations)

9 Total. Add the amounts in column (d) and column (e) . . .
10 Total tax deferred. Add the amounts in column (g). Enter here
and on line 15
. . . . . . . . . . . . . .
*You must designate any property for which you are electing to figure basis without regard to section 877A(h)(2). Identify as “(h)(2).” This election is irrevocable.
Form 8854 (2012)

Form 8854 (2012)

Page

4

Section C
Deferral of Tax
Election to defer tax. You can defer tax only if you have provided adequate security. Adequate security is described
in the instructions.
11

Are you electing to defer tax under section 877A(b)?
Checking the “Yes” box is an irrevocable waiver of any right under any treaty of the United States
that would prevent assessment or collection of any tax imposed because of section 877A.

Yes

No

If you checked the “Yes” box, continue to line 12. Otherwise, do not complete lines 12 through 15.
12

Enter the total tax you would have reported on Form 1040, line 61, for the part of the year
including the day before the expatriation date absent the deferral election . . . . . . . .

12

Enter the total tax for the same part of the tax year determined without regard to the amounts
attributable to section 877A(a). Attach computation . . . . . . . . . . . . . . . .

13

14

Subtract line 13 from line 12. This is the amount of tax eligible for deferral

.

.

.

.

.

.

.

14

15

Enter the total tax deferred from line 10, column (g) .

.

.

.

.

.

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.

15

13

.

.

.

.

.

.

.

.

• If you are filing Form 1040, enter this amount in brackets to the left of the entry space for line
61. Identify as “EXP.”
• If you are filing Form 1040NR, enter this amount in brackets to the left of the entry space for line
60. Identify as “EXP.”
Form 8854 (2012)

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Form 8854 (2012)

Part V

Balance Sheet and Income Statement

Schedule A
Balance Sheet
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
following date.
• Part II filers - the end of the tax year for which you are filing the form
• Part IV filers - your expatriation date
For more details, see the separate instructions.
Assets
1
2

(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 long-term
residents 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 . . . . . . . .

3
4
5
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 through 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
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) . . . . . . . . . . . .

Amount

Form 8854 (2012)

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Form 8854 (2012)

Income Statement
Schedule B
Provide income information for the following period.
• Part II filers - the tax year for which you are filing the form
• Part IV filers - the part of the tax year that ends with the day before your expatriation date; but enter -0- for lines 5 through 7.
1
U.S. source gross income not effectively connected with the conduct of a U.S. trade or business.
1a
a Interest . . . . . . . . . . . . . . . . . . . .
b Dividends . . . . . . . . . . . . . . . . . . . .
1b
c Royalties . . . . . . . . . . . . . . . . . . . .
1c
d Pension distributions . . . . . . . . . . . . . . . .
1d
e Other . . . . . . . . . . . . . . . . . . . . .
1e
f Total. Add lines a through e . . . . . . . . . . . . . . . . . . . . . . .
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
Gains from the sale or exchange of:
a Property (other than stock or debt obligations) located in the United
States . . . . . . . . . . . . . . . . . . . . .
4a
b Stock issued by a U.S. domestic corporation . . . . . . . .
4b
c Debt obligations of U.S. persons or of the United States, a state or
political subdivision thereof, or the District of Columbia . . . . .
4c
d Total. Add lines a through c . . . . . . . . . . . . . . . . . . . . . . .
4d
5
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 ordinarily would 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
10
Total. Add lines 8 and 9 . . . . . . . . . . . . . . . . . . . . . . . .
10

Sign Here

Paid
Preparer
Use Only

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.
Your signature

Print/Type preparer’s name

Firm’s name

▶

Firm’s address ▶

Date

Preparer’s signature

Date

Check
if
self-employed

PTIN

Firm's EIN ▶
Phone no.

Form 8854 (2012)