RRB-1001 (08-19) Nonresident Questionnaire

NONRESIDENT QUESTIONNAIRE
1. RRB Claim Number

FORM APPROVED
OMB NO. 3220-0145

2. Payee Code
5. Enter your claimed country of citizenship.

3. Your United States Taxpayer
Identification Number

6. Enter your claimed country of legal residence.
Note: If this is different than the country shown
In Item 4, you must submit proof of residency.

4. Name and Address

7. Do you claim exemption under any tax treaty in effect
between your country of legal residence and the United States?
Note: To receive an exemption, you must comply with certain
requirements. See Form TB-26 for more information about
claiming an exemption.

Yes
No

8. United Stated Passport Number
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
Not correct. I will notify the RRB within 30 days of any change in this information.
Signature _____________________________________
This certificate MUST BE SIGNED to be valid.

Click this link for instructions on completing this form

Date ____________________
Form RRB-1001 (08-19)