Form 2063 - U.s. Departing Alien Income Tax Statement Page 2
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1
2IMPORTANT
12a
Did you receive or do you expect to receive any income subject to U.S. income tax for the year shown on line
4 on the front of this form? .
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Yes
No
Please keep this certificate
with your passport
If “Yes”:
b
Yes
No
Was U.S. income tax withheld?
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c
Did you make any estimated income tax payments?
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Yes
No
Privacy Act and Paperwork Reduction Act Notice. We ask for the
information on this form to carry out the Internal Revenue laws of the United
13a
Did you receive any income subject to U.S. income tax during the prior tax year? .
Yes
No
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States. Internal Revenue Code sections 6001, 6011, 6012(a), 6851, and
their regulations require that you give us the information. Routine uses of
If “Yes,” give the following information:
this information include giving it to the Department of Justice for civil and
b
U.S. address shown on the income tax return you filed for that year:
criminal litigation and to cities, states, and the District of Columbia to carry
out their tax laws. We may also disclose this information to other countries
under a tax treaty, to federal and state agencies to enforce federal nontax
criminal laws, or to federal law enforcement and intelligence agencies to
combat terrorism. If you do not give the information asked for, you may be
charged penalties and you may be subject to criminal prosecution.
c
(2) Taxable income
(3) Tax paid
(4) Balance due
You are not required to provide the information requested on a form that
(1) Year
is subject to the Paperwork Reduction Act unless the form displays a valid
OMB control number. Books or records relating to a form or its instructions
must be retained as long as their contents may become material in the
administration of any Internal Revenue law. Generally, tax returns and
14
return information are confidential, as required by Code section 6103.
Are you liable for filing tax returns or paying taxes to the United States for any prior year not shown above? .
Yes
No
The time needed to complete and file this form will vary depending on individual
Declaration. Under penalties of perjury, I declare that I have examined the above statements, and to the best of my knowledge and belief, they are true,
circumstances. The estimated average time is: Recordkeeping, 6 min.; Learning
correct, and complete.
about the law or the form, 3 min.; Preparing the form, 26 min.; Copying,
assembling, and sending the form to the IRS, 13 min. If you have comments
Sign
concerning the accuracy of these time estimates or suggestions for making this
form simpler, we would be happy to hear from you. You can email us at
Here
*taxforms@irs.gov. (The asterisk must be included in the address.) Please put
Signature of departing alien
Date
“Forms Comment” on the subject line. Or you can write to the Internal Revenue
Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111
Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send the form to
this address.
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