Form 8854 - Expatriation Information Statement - 2002 Page 2
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Form 8854 (Rev. 2-2002)
Page
Part II
Balance Sheet
● Complete Part II only if you checked the “Yes” box on line 11 in Part I.
● List the amounts of your assets and liabilities in U.S. dollars immediately prior to expatriation.
● If you are a former U.S. long-term resident (LTR), it may benefit you to complete column (d). Only former LTRs
should do so.
For more details see the separate instructions.
(a) Fair Market Value
(b) U.S. adjusted
(c) Gain or (Loss).
(d) FMV on beginning
Assets
(FMV) immediately
basis immediately
Subtract column (b)
date of U.S. residency
prior to expatriation
prior to expatriation
from column (a)
(optional, for LTRs only)
1
Cash, including bank deposits
2
Marketable stock and securities issued by
U.S. companies
3
Marketable stock and securities issued by
foreign companies
4
Nonmarketable stock and securities issued
by U.S. companies
5
Nonmarketable stock and securities issued
by foreign companies
6
Pensions from services performed in the
United States
7
Pensions from services performed outside
the United States
8
Partnership interests (see instructions)
9
Assets held by trusts you own under
sections 671–679 (see instructions)
10
Beneficial interests in nongrantor trusts (see
instructions)
11
Intangibles used in the United States
12
Intangibles used outside the United States
13
Loans to U.S. persons
14
Loans to foreign persons
15
Real property located in the United States
16
Real property located outside the United
States
17
Business property located in the United
States
18
Business property located outside the
United States
19
Other assets (see instructions)
20
Total Assets. Add lines 1 through 19
Liabilities
Amount
21
Installment obligations
22
Mortgages, etc.
23
Other liabilities (see instructions)
24
Total Liabilities. Add lines 21 through 23
25
Net Worth. Subtract line 24 from line 20,
column (a)
8854
Form
(Rev. 2-2002)
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