1040-C U.S. Departing Alien Income Tax Return

Form

1040-C

U.S. Departing Alien Income Tax Return
For tax period or year beginning
▶

Department of the Treasury
Internal Revenue Service

Print
or
type

OMB No. 1545-0074

, 2021, and ending

,

2021

Go to www.irs.gov/Form1040C for instructions and the latest information.
▶ File original and one copy.

Your first name and initial

Last name

Your social security number

If a joint return, spouse’s first name and initial (see instructions)

Last name

Spouse’s identifying number

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

Passport or alien registration card number
Your number

Date on which you first arrived in the U.S.

Spouse’s number

City, state, and ZIP code

Date of departure

Complete foreign address

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

Of what country are you a citizen or national?

Of what country are you a resident for tax purposes?

Caution: Form 1040-C is not a final income tax return. You must file a final return on the correct form after your tax year ends.
See Final Return Required in the instructions.

Part I
1

2
3
4
5

6

Explanation of Status—Resident or Nonresident Alien—See instructions.

Check the box or boxes that apply. Note: A nonresident alien who has income from U.S. real property may elect to treat this
income as effectively connected income. Gain or loss on the disposition of a U.S. real property interest by a nonresident alien is
effectively connected income or loss. For details, see the 2020 Form 1040-NR instructions or Pub. 519, U.S. Tax Guide for Aliens.
Group I—Resident alien.
Group II—Nonresident alien with income effectively connected with a U.S. trade or business.
Group III—Nonresident alien with income not effectively connected with a U.S. trade or business.
Type of trade or business or occupation in the United States ▶
Visa number and class under which you were last admitted to the United States ▶
Do you have a permit to reenter the United States? . . . . . . . . . . . . . . . . . . .
If “Yes,” enter the expiration date ▶
Have you signed a waiver of rights, privileges, exemptions, and immunities as described under Exceptions
in the instructions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” enter the date signed ▶
During your stay in the United States did you furnish Form W-9, Request for Taxpayer Identification
Number and Certification, to a withholding agent? . . . . . . . . . . . . . . . . .

.

.

7a Have you applied for U.S. citizenship? . . . . . . . . . . . . . . . . . . . . . . .
b Have you applied for, or taken other affirmative steps to apply for, lawful permanent resident status (green
card holder) in the United States, or do you have an application pending to change your status to that of a
lawful permanent resident of the United States? . . . . . . . . . . . . . . . . . . . .

Yes

No

Yes

No

Yes
Yes

No
No

Yes

No

8
a
b
c
9
10

If you filed income tax returns in the United States, give the following information for 2020.
Type of return filed (for example, Form 1040, 1040-SR, 1040-NR, etc.) ▶
Your U.S. address, if any, shown on return ▶
Taxable income reported $
d Total tax payments $
e Balance due $
Do you know of any current charges against you concerning your U.S. taxes for any tax period? . . . .
Yes
No
Do you plan to return to the United States? . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If “Yes,” complete lines 11 through 13 below .
Yes
No
11
Are your spouse and any children remaining in the United States? . . . . . . . . . . . . . .
12
Show the approximate value and location in the United States of any property held by you.
Value
Location
a Real property
. . . . . . . . $
;
. . . . . . . . $
;
b Stocks and bonds . . . . . . . . $
;
c Cash . . . . . . . . . . . . $
;
d Other (specify) ▶
$
;
13
If you will not return to the United States before the due date for filing a final U.S. income tax return for the current year or the
due date for filing a final U.S. income tax return for the preceding year, what arrangements have you made to file the final
income tax return(s) and pay the tax(es)? ▶

{

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

Cat. No. 11310F

Form 1040-C (2021)

Page 2

Form 1040-C (2021)

Part II

Dependents—See instructions.

14 (a) First name

Last name

(b) Social security
number

(c) Relationship to
you

(d) ✓ if qualifies for (see instructions):
Child tax credit Credit for other dependents

Part III

Figuring Your Income Tax

15
16
17
Groups 18
I and II 19
20
21
22
23
Group
24

Total income (from page 3, Schedule A, line 4, column (d) or (e)) . . . . . . . . . . .
Adjustments. See the instructions and attach appropriate form or statement . . . . . . .
Adjusted gross income. Subtract line 16 from line 15 . . . . . . . . . . . . . . .
Enter the amount from page 4, Schedule D, line 6 or 12, whichever applies . . . . . . .
Credits. See the instructions and attach appropriate form or statement . . . . . . . . .
Subtract line 19 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . .
Other taxes. See the instructions and attach appropriate form . . . . . . . . . . . .
Tax for Group I or II. Add lines 20 and 21 . . . . . . . . . . . . . . . . . . .
23
Total income (from page 3, Schedule A, line 4, column (f)) . . . . . .
Tax (multiply line 23 by 30% (0.30)). If less than 30% (0.30), attach statement showing
computation. See instructions . . . . . . . . . . . . . . . . . . . . . .

III

25 Total tax. Add lines 22 and 24 . . . . . . . . . . . . . . . .
Note: Your tax liability on your final return may be different from line 25.
Tax
26
U.S. income tax paid or withheld at source (from page 3, Schedule A, lines 4
Summary
and 5, column (c)) . . . . . . . . . . . . . . . . . . .
27
28
29
30
31

Paid
Preparer
Use Only

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.

.

▶

24
25

29
30
31

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 complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Your signature

▲

Keep a copy
of this return
for your
records.

.

26
2021 estimated tax payments and amount applied from 2020 return . . .
27
28
Other payments (specify) ▶
Total payments. Add lines 26 through 28 . . . . . . . . . . . . . . . . . ▶
If line 25 is more than line 29, subtract line 29 from line 25. This is the amount you owe . . .
If line 29 is more than line 25, subtract line 25 from line 29. This is the amount you overpaid. Any
overpayment of tax will be refunded only when you file your final return for the tax year . . .

▲

Sign
Here

.

15
16
17
18
19
20
21
22

Date

(A return made by an agent must be accompanied by a power of attorney.)
Print/Type preparer’s name

Firm’s name

▶

Firm’s address

▶

Date

Spouse’s signature

(If filing jointly, both must sign even if only one had income.)

Preparer’s signature

Date

Check
if
self-employed

PTIN

Firm’s EIN ▶
Phone no.

Certificate of Compliance

This certifies that the above individual(s) has satisfied all the requirements of the Internal Revenue Code and the Internal Revenue Regulations relating to departing aliens
according to all information available to me at this date. This certificate is effective for the tax period
beginning

, 2021, and ending

,

, or the tax year ended

,

.

(Field Assistance Area Director)
Internal Revenue Service
Date

,

By
(Name)

(Title)
Form 1040-C (2021)

Page 3

Form 1040-C (2021)

Schedule A
1

2
3
4
5

(a) Payer of income

2

(b) Type of income (such as
salary, wages, taxable
interest, dividends,
rents, etc.)

Net gain, if any, from Schedule D (Form 1040)
Net gain, if any, from Schedule B, line 2 .
Totals . . . . . . . . . . . .
Exempt income. Do not include on line 4 .

Schedule B

1

Income—See instructions.
(c) Amount of U.S.
income tax paid or
withheld at source

(d) Resident alien
income

Nonresident alien income
(e) Effectively
connected with a U.S.
trade or business

2
3
4
5

Certain Gains and Losses From Sales or Exchanges by Nonresident Aliens of Property Not
Effectively Connected With a U.S. Trade or Business—See instructions. Include any U.S. income tax
that was paid or withheld on these sales or exchanges on Schedule A, line 3, column (c).

(a) Description of property
(If necessary, attach statement of
descriptive details not shown below.)

(b) Date acquired
(mo., day, yr.)

(c) Date sold
(mo., day, yr.)

(d) Sales price

(e) Cost or other
basis

Net gain. Combine the gains and losses entered on line 1, column (f). If the total is greater than zero,
enter this net gain amount on Schedule A, line 3, column (f). . . . . . . . . . . . . . . .

Schedule C

(f) Not effectively
connected with a U.S.
trade or business

(f) Gain or (loss)
subtract (e) from (d)

2

Itemized Deductions—See instructions.

• If you are a resident alien reporting income on Schedule A, column (d), you may claim the same deductions allowable on
Schedule A (Form1040).
• If you are a nonresident alien reporting income on Schedule A, column (e), you may claim only deductions that are connected to U.S.
trade or business income and not deducted elsewhere. See Schedule A (Form 1040-NR). However, casualty or theft losses and
charitable contributions do not have to be related to U.S. trade or business income. You should file Form 4684, Casualties and
Thefts, to support casualty or theft losses shown below. See instructions for the extent to which casualty and theft losses are
deductible.
• If you are a nonresident alien reporting income on Schedule A, column (f), do not claim any deductions related to that income.
1
(a) Type of deduction
(b) Amount
(c) Type of deduction
(d) Amount of
(such as interest, taxes, contributions, etc.)

2

of deduction

(such as interest, taxes, contributions, etc.)

Total itemized deductions. Add the amounts in columns (b) and (d) of line 1. Enter the total here and
on Schedule D, line 2 or line 8, whichever applies.
. . . . . . . . . . . . . . . . .

deduction

2

Form 1040-C (2021)

Page 4

Form 1040-C (2021)

Schedule D

Tax Computation—See instructions.

Tax for Resident Alien—Group I Only (For description of groups, see line 1 on page 1.)
1

Enter amount from page 2, line 17 .

2

If you itemize deductions, enter amount from page 3, Schedule C, line 2. If you do not plan to itemize
deductions, enter your standard deduction. See Standard Deduction (Group I only) in the instructions

2

3

Taxable income. Subtract line 2 from line 1

3

4

Tax. Figure your tax on the amount on line 3 by using the 2021 Tax Rate Schedules in the instructions.
Include in the total any tax from Form 4972 and Form 8814. Enter the tax here . . . . . . . .

4

5

Alternative minimum tax (AMT). Enter the amount, if any, of AMT from Form 6251

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5

6

Add lines 4 and 5. Enter the result here and on Form 1040-C, line 18

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6

Tax for Nonresident Alien With Income Effectively Connected With a U.S. Trade or Business—Group II Only
7

Enter amount from page 2, line 17 .

8

Enter itemized deductions from page 3, Schedule C, line 2

9

Taxable income. Subtract line 8 from line 7

10

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9

Tax. Figure your tax on the amount on line 9 by using the 2021 Tax Rate Schedules in the instructions.
Include in the total any tax from Form 4972 and Form 8814. Enter the tax here . . . . . . . .

10

11

Alternative minimum tax (AMT). Enter the amount, if any, of AMT from Form 6251

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11

12

Add lines 10 and 11. Enter the result here and on Form 1040-C, line 18

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12
Form 1040-C (2021)