RRB-1001 Nonresident Questionnaire

PROPOSED

NONRESIDENT QUESTIONNAIRE
1. RRB Claim Number

2. Payee Code

3. Your United States Taxpayer
Identification Number

4. Name and Address

FORM APPROVED
OMB NO. 3220-0145

5. Claimed country of citizenship.
6. Claimed country of legal residence.
Note: If this is different than the country
shown In Item 4, you must submit proof of
residency.
7. Do you claim exemption under any tax treaty in effect between
your country of legal residence and the United States?

Yes
Note: To receive an exemption, you must comply with certain
requirements. See Form TB-26 for more information about
No
claiming an exemption.
8. United States Passport Number only
Note: Passport cannot be expired.
9. I understand that making a false or fraudulent statement to the RRB is a
crime punishable by Federal law. I certify that the information provided on
this certificate is true, complete, and correct. I will notify the RRB within 30
days of any change in this information.
Signature _____________________________

Date _________________

This certificate MUST BE SIGNED to be valid.

Form RRB-1001 (xx-xx)