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

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U.S. Departing Alien Income Tax Statement
2063
Annual Certificate of Compliance
Form
(IRS Form 2063)
(Rev. September 2013)
For a Resident Alien Against Whom a Termination Assessment Has Not Been Made or
OMB No. 1545-0138
for a Nonresident Alien Having No Taxable Income From United States Sources
Department of the Treasury
This certifies that
Information about Form 2063 is available at
▶
Internal Revenue Service
1 Name (please print or type)
Social security number or ITIN, if any
has satisfied all United States of America income tax obliga-
2 U.S. address (number, street, apt. no. or rural route, city, state, and ZIP code)
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 Foreign address (street address, city or town, state or province, country, and ZIP or foreign postal code)
(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
By
card number
An employee
(Name and title)
Self-employed
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. (MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
Area Director’s Stamp
11 Are you a resident alien
of the U.S.?
Yes
No
If “No,” enter the country of which you are a resident
▶
Cat. No. 21420Y
For Privacy Act and Paperwork Reduction Act Notice, see back of form.

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