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

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Form

1040-C

(Rev. January 2024)

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

Print
or
Type

, 20

, and ending

, 20

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

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

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

TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 22, 2023
DO NOT FILE

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

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

Complete foreign address

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
7a
b

8
a
b
c
9
10
11
12
a
b
c
d
13

14

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 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? . . . . . . . . . . . . . . . . . . .
Yes
No
If “Yes,” enter the expiration date:
Have you signed a waiver of rights, privileges, exemptions, and immunities as described under Exceptions
in the instructions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
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? . . . . . . . . . . . . . . . . . . .
Yes
No
Have you applied for U.S. citizenship? . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
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
If you filed income tax returns in the United States, give the following information for the prior tax year.
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 $
Yes
No
Do you know of any current charges against you concerning your U.S. taxes for any tax period? . . . .
Do you plan to return to the United States? . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If “Yes,” complete lines 11 through 14 below .
Yes
No
Are your spouse and any children remaining in the United States? . . . . . . . . . . . . . .
Show the approximate value and location in the United States of any property held by you.
Value
Location
Real property
. . . . . . . . $
;
. . . . . . . . $
;
Stocks and bonds . . . . . . . . $
;
Cash . . . . . . . . . . . . $
;
Other (specify):
$
;

{

At any time during the tax year, did you: (a) receive (as a reward, award, or payment for property or
services); or (b) sell, exchange, or otherwise dispose of a digital asset (or a financial interest in a digital
Yes
No
asset)? (See instructions.) . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 (Rev. 1-2024)

Page 2

Form 1040-C (Rev. 1-2024)

Part II

Dependents—See instructions.

15
(a) First name

(b) Social security
number

Last name

(c) Relationship
to you

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

If more
than four
dependents,
see instructions.

Part III
16
17
18
Groups 19
I and II 20
21
22
23
24
Group
25
III

TREASURY/IRS
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June 22, 2023
DO NOT FILE
Figuring Your Income Tax

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 17 from line 16 . . . . . . . . . . . . . . .
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 20 from line 19. If zero or less, enter -0- . . . . . . . . . . . . . . .
Other taxes. See the instructions and attach appropriate form . . . . . . . . . . . .
Tax for Group I or II. Add lines 21 and 22 . . . . . . . . . . . . . . . . . . .
Total income (from page 3, Schedule A, line 4, column (f)) . . . . . .
24
Tax (multiply line 24 by 30% (0.30)). If less than 30% (0.30), attach statement showing computation.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . .
26 Total tax. Add lines 23 and 25 . . . . . . . . . . . . . . . . . . . . . .
Note: Your tax liability on your final return may be different from line 26.
Tax
27 U.S. income tax paid or withheld at source (from page 3, Schedule A, lines 4
Summary
and 5, column (c)) . . . . . . . . . . . . . . . . . . .
27
28 Current year’s estimated tax payments and amount applied from preceding
year’s tax return . . . . . . . . . . . . . . . . . . . .
28
29 Other payments (specify):
29
30 Total payments. Add lines 27 through 29 . . . . . . . . . . . . . . . . . .
31 If line 26 is more than line 29, subtract line 30 from line 26. This is the amount you owe . . .
32 If line 30 is more than line 26, subtract line 26 from line 30. 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
Joint return?
See instructions.
Keep a copy for
your records.

Paid
Preparer
Use Only

16
17
18
19
20
21
22
23

25
26

30
31

32

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

Date

Your occupation

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

Spouse’s signature. If a joint return, both must sign.

Date

Spouse’s occupation

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

Phone no.
Print/Type preparer’s name

Email address
Preparer’s signature

Date

Check
if
self-employed

Firm’s name

Firm’s EIN

Firm’s address

Phone no.

PTIN

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

, 20

, and ending

, 20

, or the tax year ended

, 20

.

(Field Assistance Area Director)
Internal Revenue Service
Date

,

By
(Name)

(Title)
Form 1040-C (Rev. 1-2024)

Page 3

Form 1040-C (Rev. 1-2024)

Schedule A

Income—See instructions.

1
(a) Payer of income

2
3
4
5

2

(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

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

TREASURY/IRS
AND OMB USE
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June 22, 2023
DO NOT FILE

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

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

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) 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

2

(a) Type of deduction
(such as interest, taxes, contributions, etc.)

(b) Amount
of deduction

(c) Type 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 . . . . . . . . . . . . . . .

(d) Amount of
deduction

2
Form 1040-C (Rev. 1-2024)

Page 4

Form 1040-C (Rev. 1-2024)

Schedule D

Tax Computation—See instructions.

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

1

Enter amount from page 2, line 18 .

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 current year’s 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 19

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TREASURY/IRS
AND OMB USE
ONLY DRAFT
June 22, 2023
DO NOT FILE
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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 18 .

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 current year’s 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 19

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12

Form 1040-C (Rev. 1-2024)