Form 2063 - U.s. Departing Alien Income Tax Statement

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2063
U.S. Departing Alien Income Tax Statement
Annual Certificate of Compliance
Form
(Rev. June 2011)
(IRS Form 2063)
OMB No. 1545-0138
For a Resident Alien Against Whom a Termination Assessment Has Not Been Made or
Department of the Treasury
For a Nonresident Alien Having No Taxable Income From United States Sources
Internal Revenue Service
1 Name (please print or type)
Social security number or ITIN, if any
This certifies that
2 U.S. address (number, street, and apt. no. or rural route)
City
State and ZIP code
has satisfied all United States of America income tax obliga-
tions with respect to income received or to be received for
the tax year ended
,
,
determined to the extent practicable, based on all information
available to me on this date.
3 Complete foreign address
(Field Assistance Area Director)
Internal Revenue Service
5 While in the U.S., check if you were:
4 Tax year
6 Of what country are you a citizen or subject?
7 Passport or alien registration
card number
An employee
By
Self-employed
(Name and title)
8 Date of departure
9 Original date of your entry into the U.S.
10 Date on which you last arrived in the U.S.
11 Are you a resident alien
of the U.S.?
Yes
No
Area Director’s Stamp
If “No,” enter the country of which you are a resident
▶
For Privacy Act and Paperwork Reduction Act Notice, see back of form.
Cat. No. 21420Y

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