8854 Initial and Annual Expatriation Information Statement

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Form

8854

Initial and Annual Expatriation Statement
For calendar year 2021 or other tax year beginning

Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-0074

, 2021, and ending

Name

Part I

2021

, 20

Go to www.irs.gov/Form8854 for instructions and the latest information.
▶ Please print or type.

Attachment
Sequence No. 112
Identifying number (see instructions)

General Information. For all filers.

DRAFT AS OF
September 29, 2021
DO NOT FILE
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

Check the box that applies. See instructions.

Initial expatriation statement for persons who expatriated in 2021. Complete Part II.
Annual expatriation statement for persons who expatriated before 2021. Complete Part III.

5

Date of expatriation under section 877A(g)(3) for expatriating citizens and long-term residents. See instructions.

Citizen
Long-term resident
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

List all countries (including the United States) of which you are a citizen (see instructions).
a

Name of country

b Date you became a citizen of each country listed in line 6a (see instructions).
7

How you became a U.S. citizen

8

Date you became a U.S. lawful permanent resident

Part II

By birth

By naturalization

Initial Expatriation Statement for Persons Who Expatriated in 2021

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 your 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 (including the year of your expatriation)? . . . . . . . . . . . . . . . .

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 tax 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

For Paperwork Reduction Act Notice, see the separate instructions.

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Cat. No. 24126N

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$

Form 8854 (2021)

Page 2

Form 8854 (2021)

Section B
Balance Sheet
List in U.S. dollars the fair market value and the U.S. adjusted basis of your assets and liabilities as of your expatriation date. For Lines
6 and 7, list in U.S. dollars the present value of your pensions and deferred compensation interests as of your expatriation date. For
more details, see the instructions.
(a) Fair market
value (FMV)

Assets

(b) U.S. adjusted
basis

DRAFT AS OF
September 29, 2021
DO NOT FILE
1
2
3
4
5
a

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
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

Pensions or similar retirement arrangements (both U.S. and
foreign). See instructions . . . . . . . . . . . . .

7
8
9
10
11
12
13
14
15
16
17
18
19
20

Deferred compensation (including stock options). See instructions
Partnership interests. See instructions . . . . . . . .
Assets held in trust. See instructions . . . . . . . . .
Beneficial interests in trusts not included in line 9. 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. Don’t
include amounts on line 5a in this total . . . . . . . .

21
22
23
24
25

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
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Form 8854 (2021)

Page 3

Form 8854 (2021)

Section C
Property Owned on Date of Expatriation
Don’t complete Section C if:
• Your average net income tax liability for the 5 tax years immediately before expatriation (see line 1 in Section A) wasn’t more
than $172,000, your net worth on the date of your expatriation (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.

DRAFT AS OF
September 29, 2021
DO NOT FILE
1a

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

Yes

No

Yes

No

c

Do you have an interest in a specified tax deferred accounts? If “Yes,” you must include in income the
amount of your entire interest in the account on the day before your expatriation date . . . . . . .

d Are you a beneficiary of a nongrantor trust? See instructions

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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.

2

Recognition of gain or loss on the deemed sale of mark-to-market property. Caution: Don’t include in column (a) any
property described on line 1a, 1b, 1c, or 1d.

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)

3 Total. Add the amounts in column (d) and column (e) . . .
4 Total tax deferred. Add the amounts in column (g). Enter here
and on Part II, Section D, line 5 . . . . . . . . .
* You must identify as “(h)(2)” any property for which you are making the special basis election under section 877A(h)(2). This election is irrevocable.
See the instructions for Part II, Section C, line 2, column (c).
Form 8854 (2021)

Form 8854 (2021)

Page

4

Section D
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.
1

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

DRAFT AS OF
September 29, 2021
DO NOT FILE
If you checked the “Yes” box, continue to line 2. Otherwise, don’t complete lines 2 through 5.

2

Enter the total tax you would have reported, absent the deferral election, on Form 1040 or
1040-SR, line 24, for the part of the year including the day before the expatriation date absent the
deferral election . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 . . . . . . . . . . . . . . . .

2

4

Subtract line 3 from line 2. This is the amount of tax eligible for deferral

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4

5

Enter the total tax deferred from Part II, Section C, line 4, column (g)

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5

3

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3

• If you are filing Form 1040 or 1040-SR, enter this amount in brackets to the left of the entry
space for line 24. Identify as “EXP.”
• If you are filing Form 1040-NR, enter this amount in brackets to the left of the entry space for line
24. Identify as “EXP.”

Part III

Annual Expatriation Statement for Persons Who Expatriated Before 2021

• 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 are a beneficiary of 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 2021 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)

Form 8854 (2021)

Form 8854 (2021)

Part III
2

Page

5

Annual Expatriation Statement for Persons Who Expatriated Before 2021 (continued)

Did you receive any distributions of eligible deferred compensation items for 2021? . .
If “Yes,” enter the amount of distribution(s) and amount withheld at source, if any, below.
Amount of distribution

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Yes

No

Amount withheld at source, if any

1
2
3

DRAFT AS OF
September 29, 2021
DO NOT FILE
3

Did you receive any distributions from a nongrantor trust for 2021? . . . . . . . .
If “Yes,” enter the amount of distribution(s) and amount withheld at source, if any, below.
Amount of distribution

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Yes

No

Amount withheld at source, if any

1
2
3

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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 (2021)