Form 1040nr-Ez - U.s. Income Tax Return For Certain Nonresident Aliens With No Dependents - Dpeartment Of The Treasury Page 2

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2
Form 1040NR-EZ (2009)
Page
Other Information (see page 10)
A
Of what country or countries were you a citizen or national during the tax year?
B
In what country did you claim residence for tax purposes during the tax year?
Yes
No
C
Have you ever applied to be a green card holder (lawful permanent resident) of the United States?
D
Were you ever:
Yes
No
1. A U.S. citizen?
Yes
No
2. A green card holder (lawful permanent resident) of the United States?
If you answer “Yes” to 1 or 2, see Pub. 519, chapter 4, to see expatriation rules that apply to you.
E What was your visa type on the last day of the tax year?
F
Have you ever changed your visa type (nonimmigrant status)?
Yes
No
G
List all dates you entered and left the United States during 2009 (see page 10).
Note. If you are a resident of Canada or Mexico AND enter and leave the United States at frequent
intervals, check the box for Canada or Mexico and skip to question H
Canada
Mexico
Date entered United States
Date departed United States
Date entered United States
Date departed United States
mm/dd/yy
mm/dd/yy
mm/dd/yy
mm/dd/yy
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Give number of days (including vacation, nonworkdays, and partial days) you were present in the United States during
H
2007
, 2008
, and 2009
.
Did you file a U.S. income tax return for any prior year?
Yes
No
I
If “Yes,” give the latest year and form number you filed
Income Exempt from Tax—If you are claiming the benefits of a U.S. income tax treaty with a foreign country, complete 1
J
and 2 below. See Pub. 901 for more information on tax treaties.
Enter the name of the country, the applicable tax treaty article, the number of months in prior years you claimed the
1.
treaty benefit, and the amount of exempt income in the columns below. Attach Form 8833 if required (see page 10).
(b) Tax treaty
(c) Number of months
(d) Amount of exempt
(a) Country
claimed in prior tax years
income in current tax year
article
(e) Total. Enter this amount on Form 1040NR-EZ, line 6. Do not enter it on line 3 or line 5
2. Were you subject to tax in a foreign country on any of the income shown in 1(d) above?
Yes
No
1040NR-EZ
Form
(2009)

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