Form 9210 - Alien Status Questionnaire Page 2
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11. Were you employed in the United States
Yes
No
If Yes, please complete the following
a. Were there any restrictions on the length of your employment
Yes
No
b. If Yes to a. above, please state what the restrictions were
c. Name and address of employer
12. Did you file a foreign income tax return with a foreign country while you were a
Yes
No
resident in the United States
If Yes, please provide us with a copy of the foreign tax return
13. Are you employed in the United States by the same employer for whom you worked
Yes
No
Not employed
in the foreign country prior to your move to the United States
14. Did you leave the United States after you first arrived
Yes
No
Did not leave
If Yes, please complete the following
Did you intend to return
Yes
No
When did you intend to return?
Yes
No
Did you obtain a reentry permit
What was the expiration date
of the permit
(including any extensions)
Did you give up your United States residence when you departed the United States
Yes
No
What was the date of your final departure from the United States
How much income did you earn outside the United States in the year of your final departure
15. Please provide us in the space below all the dates of your arrival in, and departures from, the United States from the date you first
arrived in the United States, and the purpose of each departure from the United States
Arrival Date
Departure Date
Purpose
Remarks
Certification: Under penalty of perjury, I declare that I have examined this statement and, to the best of my knowledge and belief, it is
true, correct, and complete
Taxpayer's signature
Date
9210
Catalog Number 11842U
Form
(Rev. 7-2015)
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