Form 1040-C - U.s. Departing Alien Income Tax Return - 2017 Page 2
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Form 1040-C (2017)
Page
Part II
Exemptions
Group I — If you are a resident alien, you may claim the same exemptions allowed U.S. citizens on Form 1040.
Group II — If you are a nonresident alien with income effectively connected with a U.S. business, you may claim one exemption.
Residents of Canada, India, Mexico, or South Korea, or U.S. nationals, see the instructions.
Group III — If you are a nonresident alien with income not effectively connected with a U.S. business, do not claim any exemptions for that income.
14a
Yourself
b
Spouse
Boxes checked on 14a
and 14b
Caution: If someone can claim you as a dependent on his or her 2017 tax return, do not check box 14a.
No. of children on
14c who:
✓
c
(3) Dependent’s
Dependents:
(4)
if qualifying
(2) Dependent’s
relationship
child for child tax
• lived with you
SSN or ITIN
(1) First name
Last name
to you
credit
• did not live with you
due to divorce or
separation
Dependents on 14c
not entered above
Add numbers on lines
d Total number of exemptions claimed .
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above
▶
Part III
Figuring Your Income Tax
15 Total income (from page 3, Schedule A, line 4, column (d) or (e)) .
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15
16 Adjustments. See the instructions and attach appropriate form or statement .
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16
17 Adjusted gross income. Subtract line 16 from line 15 .
17
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18 Enter the amount from page 4, Schedule D, line 8 or 16, whichever applies
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18
Groups
I and II
19 Credits. See the instructions and attach appropriate form or statement .
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20 Subtract line 19 from line 18. If zero or less, enter -0- .
20
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21 Other taxes. See the instructions and attach appropriate form .
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22 Tax for Group I or II. Add lines 20 and 21 .
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22
Group
23 Total income (from page 3, Schedule A, line 4, column (f)) .
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23
III
24 Tax (30% of line 23). If less than 30%, attach statement showing computation .
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24
25 Total tax. Add lines 22 and 24 .
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25
▶
Note: Your tax liability on your final return may be different from line 25.
26 U.S. income tax paid or withheld at source (from page 3, Schedule
Tax
Summary
A, lines 4 and 5, column (c)) .
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26
27 2017 estimated tax payments and amount applied from 2016
return
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27
28 Other payments (specify)
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29 Total payments. Add lines 26 through 28
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30 If line 25 is more than line 29, subtract line 29 from line 25. This is the amount you owe
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31 If line 29 is more than line 25, subtract line 25 from line 29. This is the amount you overpaid.
Any overpayment of tax will be refunded only when you file your final return for the tax year
31
Sign
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.
Here
Keep a copy
of this return
Your signature
Date
Spouse’s signature
Date
for your
(A return made by an agent must be accompanied by a power of attorney.)
(If filing jointly, both must sign even if only one had income.)
records.
Print/Type preparer’s name
Preparer’s signature
Date
PTIN
Check
if
Paid
self-employed
Preparer
Firm’s name
Firm’s EIN
Use Only
▶
▶
Firm’s address
Phone no.
▶
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
, 2017, and ending
,
, or the tax year ended
,
.
(Field Assistance Area Director)
Internal Revenue Service
Date
,
By
(Name)
(Title)
1040-C
Form
(2017)
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