Form 8854 - Initial And Annual Expatriation Statement - 2015 Page 5
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65
Form 8854 (2015)
Page
Part V
Balance Sheet and Income Statement
Schedule A
Balance Sheet
List in U.S. dollars the fair market value (column (a)) and the U.S. adjusted basis (column (b)) of your assets and liabilities as of the
following date.
• Part II filers - the end of the tax year for which you are filing the form
• Part IV filers - your expatriation date. Note: Part IV filers do not complete column (d).
For more details, see the separate instructions.
d) FMV on beginning
(
(c) Gain or (loss).
date of U.S. residency
(a) Fair market
(b) U.S. adjusted
Assets
Subtract column (b)
(optional, for long-term
value (FMV)
basis
from column (a)
residents only)
1
Cash, including bank deposits .
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2
Marketable stock and securities issued by
U.S. companies .
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3
Marketable stock and securities issued by
foreign companies .
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4
Nonmarketable stock and securities issued
by U.S. companies .
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5
Nonmarketable stock and securities issued
by foreign companies .
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a Separately state stock issued by foreign
companies that would be controlled foreign
corporations if you were still a U.S. citizen or
permanent resident (see instructions) .
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b Provide the name, address, and EIN, if any,
of any such company
6
Pensions from services performed in the
United States
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7
Pensions from services performed outside
the United States .
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8
Partnership interests (see instructions)
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9
Assets held by trusts you own under
sections 671 through 679 (see instructions)
10
Beneficial interests in nongrantor trusts (see
instructions) .
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11
Intangibles used in the United States .
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12
Intangibles used outside the United States .
13
Loans to U.S. persons
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14
Loans to foreign persons .
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15
Real property located in the United States .
16
Real property located outside the United States .
17
Business property located in the United
States .
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18
Business
property
located
outside
the
United States
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19
Other assets (see instructions) .
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20
Total assets. Add lines 1 through 5 and lines
6 through 19. Do not include amounts on
line 5a in this total .
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Liabilities
Amount
21
Installment obligations
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22
Mortgages, etc. .
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23
Other liabilities (see instructions) .
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24
Total liabilities. Add lines 21 through 23 .
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25
Net worth. Subtract line 24 from line 20,
column (a) .
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8854
Form
(2015)
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