Fillable Form 8854 - Expatriation Information Statement

OMB No. 1545-1567

8854

Expatriation Information Statement

Form

(Rev. February 2002)

Attachment

Department of the Treasury

See separate instructions.

Please print or type.

112

Sequence No.

Internal Revenue Service

Name

Date of birth (mo., day, yr.)

Telephone number

Identifying number

Part I

General Information. All filers must complete Part I. Complete Part II if, on the date of expatriation, you

had gross assets with a collective fair market value of more than $500,000. See instructions.

1 Date of expatriation

2a If you are a former U.S. citizen, check this box

If you are a former U.S. long-term resident (LTR), check this box

Mailing address where you may be reached after expatriation 4 Address of tax residence after expatriation (if different from 3)

5 Address of tax residence before expatriation

List all foreign countries (not the United States) of which you are a citizen.

a Name of country

b How you became a citizen

c Date you became a citizen

Tax year of expatriation

Number of days you were present

Tax year before expatriation

in the United States during the

Tax year that is 2 years before expatriation

Was your average annual net U.S. income tax liability (after credits) for the 5-tax-year period that ended before

the date of expatriation more than $120,000 (for expatriation in 2002), $116,000 (for expatriation in 2001), or

the applicable threshold amount (see instructions for this line) for expatriation before 2001?

Yes

If “Yes,” enter your tax liability for each of those years (rounded to the nearest $50,000).

5th Year

4th Year

3rd Year

2nd Year

1st Year

Before Expatriation

Was your net worth on the date you expatriated equal to or more than $599,000 (for expatriation in 2002),

$580,000 (for expatriation in 2001), or the applicable threshold amount (see instructions for this line) for

expatriation before 2001?

Yes

If you checked the “Yes” box on line 8 or line 9, see instructions and complete lines 10 a, b, and c.

Otherwise, go to line 11.

Are you eligible to submit a ruling request that your expatriation did not have, as one of its principal

purposes, the avoidance of U.S. taxes?

Yes

Did you submit or do you intend to submit such a ruling request?

Yes

If you submitted a ruling request, did you receive a ruling that either:

(1) Your ruling request was complete and submitted in good faith?

Yes

(2) Your expatriation did not have as one of its principal purposes the avoidance of U.S. taxes under

Internal Revenue Code section 877(a)(1)?

Yes

On the date of expatriation, did you have gross assets with an aggregate fair market value of more than $500,000?

Yes

If “Yes,” complete Part II on the back.

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

Date

Sign

Here

Date

Preparer’s signature

8854

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 24126N

Form

(Rev. 2-2002)