Form 8854 - Initial And Annual Expatriation Statement - 2015 Page 2
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Form 8854 (2015)
Page
Part III
For Persons Who Expatriated After June 16, 2008, and Before January 1, 2015
• If you made an election to defer the payment of tax, complete line 1.
• If you have an item of eligible deferred compensation, complete line 2.
• If you have an interest in a nongrantor trust, complete line 3.
1
Complete columns (a), (b), and (c) for all property on which you deferred tax on a prior year Form 8854. Complete column (d)
for any property you disposed of in 2015 and see the instructions for Part III.
(a)
(b)
(c)
(d)
Description of property
Amount of mark-to-market gain or
Amount of tax deferred on prior year
Date of disposition (if any)
(loss) reported on prior year
Form 8854
Form 8854
2
Yes
No
Did you receive any distributions of eligible deferred compensation items for 2015?
If “Yes,” Amount of distribution:
Amount withheld at source, if any:
3
Yes
No
Did you receive any distributions from a nongrantor trust for 2015?
If “Yes,” Amount of distribution:
Amount withheld at source, if any:
Part IV
For Persons Who Expatriated During 2015
Section A
Expatriation Information
1
Enter your U.S. income tax liability (after foreign tax credits) for the 5 tax years ending before the date of expatriation.
1st Year
2nd Year
3rd Year
4th Year
5th Year
Before Expatriation
Before Expatriation
Before Expatriation
Before Expatriation
Before Expatriation
$
$
$
$
$
2
Enter your net worth on the date of your expatriation for tax purposes .
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$
3
Did you become at birth a U.S. citizen and a citizen of another country, and do you continue to be a citizen
of, and taxed as a resident of, that other country?
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Yes
No
4
If you answered “Yes” to question 3, have you been a resident of the United States for not more than 10 of
the last 15 tax years? .
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Yes
No
5
Were you under age 18
/
on the date you expatriated and have you been a U.S. resident for not more than
1
2
10 years? .
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Yes
No
6
Do you certify under penalties of perjury that you have complied with all of your tax obligations for the 5
preceding tax years (see instructions)? .
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Yes
No
8854
Form
(2015)
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