1040-NR U.S. Nonresident Alien Income Tax Return

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Form

1040-NR U.S. Nonresident Alien Income Tax Return 2021
Department of the Treasury—Internal Revenue Service

Filing
Status

Single

Check only
one box.

Married filing separately (MFS)

(99)

OMB No. 1545-0074

IRS Use Only—Do not write
or staple in this space.

Qualifying widow(er) (QW)

If you checked the QW box, enter the child’s name if the
qualifying person is a child but not your dependent ▶

Your first name and middle initial

Your identifying number
(see instructions)

Last name

DRAFT AS OF
October 26, 2021
DO NOT FILE

Home address (number and street or rural route). If you have a P.O. box, see instructions.
City, town, or post office. If you have a foreign address, also complete spaces below. State

Foreign postal code

Yes

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency?

Dependents

(see instructions):

(1) First name

Last name

Individual
Estate or Trust

ZIP code

Foreign province/state/county

Foreign country name

Check if:

Apt. no.

(2) Dependent’s
identifying number

No

(4) ✔ if qualifies for (see instr.):
Credit for other
dependents

(3) Dependent’s
relationship to you

Child tax credit

If more than four
dependents, see
instructions and
check here ▶

Income
Effectively
Connected
With U.S.
Trade or
Business

1a
b
c

Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . .
Scholarship and fellowship grants. Attach Form(s) 1042-S or required statement. See instructions .
Total income exempt by a treaty from Schedule OI (Form 1040-NR), Item
L, line 1(e) . . . . . . . . . . . . . . . . . . .

2a

Tax-exempt interest .

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2a

1c
b Taxable interest .

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3a
4a
5a

Qualified dividends . .
IRA distributions . . .
Pensions and annuities .

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3a
4a
5a

b Ordinary dividends .
b Taxable amount . .
b Taxable amount . .

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6
7
8

Reserved for future use . . . . . . . . . . . . . . . . . . . . .
Capital gain or (loss). Attach Schedule D (Form 1040) if required. If not required, check here .
Other income from Schedule 1 (Form 1040), line 10 . . . . . . . . . . . . .

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9
10
a

Add lines 1a, 1b, 2b, 3b, 4b, 5b, 7, and 8. This is your total effectively connected income .
Adjustments to income:
10a
From Schedule 1 (Form 1040), line 26 . . . . . . . . . . .

b
c
d

1a
1b

2b
3b
4b
5b

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6
7
8

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▶

9

▶

Reserved for future use . . . . . . . . . . . . . .
Scholarship and fellowship grants excluded . . . . . . . .
Add lines 10a and 10c. These are your total adjustments to income

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10b
10c
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10d

11

Subtract line 10d from line 9. This is your adjusted gross income

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11

12a

Itemized deductions (from Schedule A (Form 1040-NR)) or, for certain
residents of India, standard deduction. See instructions . . . . .

b
c
13a
b

Charitable contributions for certain residents of India. See instructions
Add lines 12a and 12b . . . . . . . . . . . . . .
Qualified business income deduction from Form 8995 or Form 8995-A
Exemptions for estates and trusts only. See instructions . . . .

12a
12b
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13a
13b

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12c

c
14
15

Add lines 13a and 13b . . . . . . . . . . . . . . .
Add lines 12c and 13c . . . . . . . . . . . . . . .
Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- .

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13c
14

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

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Cat. No. 11364D

15
Form 1040-NR (2021)

Page 2

Form 1040-NR (2021)

16

Tax (see instructions). Check if any from Form(s):

1

2

17
18
19

Amount from Schedule 2 (Form 1040), line 3 . . . . . . . . . . . .
Add lines 16 and 17 . . . . . . . . . . . . . . . . . . .
Nonrefundable child tax credit or credit for other dependents from Schedule 8812

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17
18
19

20
21
22

Amount from Schedule 3 (Form 1040), line 8 . . .
Add lines 19 and 20 . . . . . . . . . .
Subtract line 21 from line 18. If zero or less, enter -0-

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20
21
22

23a

Tax on income not effectively connected with a U.S. trade or business
from Schedule NEC (Form 1040-NR), line 15 . . . . . . . . .

8814

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3

4972

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16

DRAFT AS OF
October 26, 2021
DO NOT FILE
b

c
d

Sign
Here

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23d

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24

25
a
b
c
d

Federal income tax withheld from:
Form(s) W-2 . . . . . .
Form(s) 1099 . . . . . .
Other forms (see instructions) .
Add lines 25a through 25c . .

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25a
25b
25c
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25d

Form(s) 8805 .
Form(s) 8288-A
Form(s) 1042-S

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25e
25f
25g

26
27

2021 estimated tax payments and amount applied from 2020 return .
Reserved for future use . . . . . . . . . . . . . .

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27

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26

28

Refundable child tax credit or additional child tax credit from Schedule
8812 (Form 1040)
. . . . . . . . . . . . . . . .

29
30

Credit for amount paid with Form 1040-C
Reserved for future use . . . . . .

31
32
33

Amount from Schedule 3 (Form 1040), line 15 . . . . . . . .
31
Add lines 28, 29, and 31. These are your total other payments and refundable credits .
Add lines 25d, 25e, 25f, 25g, 26, and 32. These are your total payments . . . . .

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▶

32
33

34
35a
▶b

If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid
. .
Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . ▶
▶ c Type:
Routing number
Checking
Savings

e

If you want your refund check mailed to an address outside the United States not shown on page 1,
enter it here.
▶
Amount of line 34 you want applied to your 2022 estimated tax
.
36
Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions
. ▶
▶
Estimated tax penalty (see instructions) . . . . . . . . .
38

36
37
38

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28
29
30

▶

34
35a

Account number

37

Do you want to allow another person to discuss this return with the IRS?
See instructions . . . . . . . . . . . . . . . . . . . . ▶

Yes. Complete below.

Designee’s
name ▶

Personal identification
▶
number (PIN)

Phone
no. ▶

No

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

▲

Paid
Preparer
Use Only

23a

1040),
. .
23b
. .
23c
. . . . .

.

▶

Third Party
Designee

from Schedule 2 (Form
. . . . . . .
. . . . . . .
. . . . . . .

Add lines 22 and 23d. This is your total tax .

Direct deposit?
See instructions. ▶
d

Amount
You Owe

tax,
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.
.

24

e
f
g

Refund

Other taxes, including self-employment
line 21 . . . . . . . . . .
Transportation tax (see instructions) .
Add lines 23a through 23c . . . .

Phone no.
Preparer’s name

Date

Email address
Preparer’s signature

Firm’s name ▶
Firm’s address ▶

Go to www.irs.gov/Form1040NR for instructions and the latest information.

If the IRS sent you an Identity
Protection PIN, enter it here
(see inst.) ▶

Your occupation

Date

PTIN

Check if:
Self-employed

Phone no.
Firm’s EIN ▶
Form 1040-NR (2021)