Form 8854 - Initial And Annual Expatriation Statement - 2015 Page 6
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Form 8854 (2015)
Page
Schedule B
Income Statement
Provide income information for the following period.
• Part II filers - the tax year for which you are filing the form
• Part IV filers - the part of the tax year that ends with the day before your expatriation date; but enter -0- for lines 5 through 7.
1
U.S. source gross income not effectively connected with the conduct of a U.S. trade or business.
a Interest
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1a
b Dividends .
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1b
c Royalties .
1c
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d Pension distributions .
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1d
e Other .
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1e
f
Total. Add lines a through e .
1f
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2
Gross income that is effectively connected with the conduct of a U.S. trade or business .
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3
Income from the performance of services in the United States
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3
4
Gains from the sale or exchange of:
a Property (other than stock or debt obligations) located in the United
States .
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4a
b Stock issued by a U.S. domestic corporation .
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4b
c Debt obligations of U.S. persons or of the United States, a state or
political subdivision thereof, or the District of Columbia .
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4c
d Total. Add lines a through c .
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4d
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Income or gain derived from certain foreign corporations to the extent of your share of earnings
and profits earned or accumulated before the date of expatriation (see instructions)
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5
6
Gains on certain exchanges of property that ordinarily would not be recognized (see instructions)
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7
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Income received or accrued by certain foreign corporations (see instructions)
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8
Add lines 1f, 2, 3, 4d, 5, 6, and 7 .
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9
Gross income from all other sources .
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9
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Total. Add lines 8 and 9 .
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10
Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the
best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than filer) is based on all information
of which preparer has any knowledge.
Sign Here
Your signature
Date
Print/Type preparer’s name
PTIN
Preparer’s signature
Date
Paid
Check
if
self-employed
Preparer
Firm’s name
Firm's EIN
Use Only
▶
▶
Firm’s address
Phone no.
▶
8854
Form
(2015)
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