Form 8854 - Initial And Annual Expatriation Statement - 2015
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68854
Initial and Annual Expatriation Statement
OMB No. 1545-0074
2015
Form
For calendar year 2015 or other tax year beginning
, 2015, and ending
, 20
Information about Form 8854 and its separate instructions is at
Department of the Treasury
▶
Attachment
112
Internal Revenue Service
Please print or type.
Sequence No.
▶
Name
Identifying number (see instructions)
Part I
General Information. For all filers.
1
Mailing address and telephone number where you can be reached after expatriation
2
Address of principal foreign residence (if different from line 1)
3
Country of tax residence (if different from line 2)
4
Expatriation date. Check the box that applies (see instructions).
June 4, 2004 – June 16, 2008. Complete Parts II and V
June 17, 2008 – December 31, 2014. Complete Part III if:
• You made an election to defer the payment of tax on a prior year Form 8854,
• You have an item of eligible deferred compensation, or
• You have an interest in a nongrantor trust.
Otherwise, you do not need to file Form 8854.
January 1, 2015 – December 31, 2015. Complete Parts IV and V
5
Date of notification of expatriating act, termination of residency, or claim of treaty benefits (see instructions).
Citizen. Date notification given to Department of State
Long-term resident. Date notification given to Department of Homeland Security
Long-term resident with dual residency in a treaty country. Date commencing to be treated, for tax purposes, as a
resident of the treaty country
6
Number of days you were physically present in the United States in the current year
7
List all countries (other than the United States) of which you are a citizen.
a Name of country
b Date you became a citizen of each country listed in line 7a
8
How you became a U.S. citizen
By birth
By naturalization
Part II
For Persons Who Expatriated After June 3, 2004, and Before June 17, 2008
1
Did you complete Form 8854 for any period after June 3, 2004, and before June 17, 2008?
No. If you expatriated for immigration purposes after June 3, 2004, and before June 17, 2008, but have not previously
filed a Form 8854, you continue to be treated as a U.S. citizen or U.S. lawful permanent resident for U.S. income tax
purposes until the day that you file this form. Because you did not file Form 8854 for the year of expatriation for
immigration purposes, you are subject to the alternative tax in section 877(b) for the 10-year period beginning on the date
that you file this form (see instructions).
Yes. Tax year for which Form 8854 first filed
. Go to line 2.
2
Were you physically present in the United States for more than 30 days but not more than 60 days
Yes
No
during the tax year?
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a If you checked “Yes” to line 2, were you performing services for an unrelated employer?
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Yes
No
b If you checked “Yes” to line 2a, are you a citizen or resident, fully liable for income tax, in the country in
which you were born, your spouse was born, or either of your parents was born? .
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Yes
No
Next: Go to Part V.
8854
For Paperwork Reduction Act Notice, see the separate instructions.
Form
(2015)
Cat. No. 24126N
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