Form 8802 - Application For United States Residency Certification
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38802
Application for United States
Form
Residency Certification
OMB No. 1545-1817
(Rev. April 2012)
Department of the Treasury
See separate instructions.
▶
Internal Revenue Service
Important. For applications filed after March 31, 2012, the user fee is $85 per application.
For IRS use only:
Pmt Amt $
.
Additional request (see instructions)
Foreign claim form attached
Deposit Date:
/
/
Date Pmt Vrfd:
/
/
Electronic payment confirmation no.
▶
Applicant’s name
Applicant’s U.S. taxpayer identification number
If a joint return was filed, spouse’s name (see instructions)
If a joint return was filed, spouse’s U.S. taxpayer
identification number
If a separate certification is needed for spouse, check here
▶
1
Applicant’s name and taxpayer identification number as it should appear on the certification if different from above
2
Applicant’s address during the calendar year for which certification is requested, including country and ZIP or postal code. If a P.O.
box, see instructions.
3a
Mail Form 6166 to the following address:
b
Appointee Information (see instructions):
Appointee Name
CAF No.
▶
▶
(
)
(
)
Phone No.
Fax No.
▶
▶
4
Applicant is (check appropriate box(es)):
a
Individual. Check all applicable boxes.
U.S. citizen
U.S. lawful permanent resident (green card holder)
Sole proprietor
Other U.S. resident alien. Type of entry visa
▶
Current nonimmigrant status
and date of change (see instructions)
▶
▶
Dual-status U.S. resident (see instructions). From
to
▶
to
Partial-year Form 2555 filer (see instructions). U.S. resident from
▶
▶
b
Partnership. Check all applicable boxes.
U.S.
Foreign
LLC
c
Trust. Check if:
Grantor (U.S.)
Simple
Rev. Rul. 81-100 Trust
IRA (for Individual)
Grantor (foreign)
Complex
Section 584
IRA (for Financial Institution)
d
Estate
e
Corporation. If incorporated in the United States only, go to line 5. Otherwise, continue.
Check if:
Section 269B
Section 943(e)(1)
Section 953(d)
Section 1504(d)
Country or countries of incorporation
▶
If a dual-resident corporation, specify other country of residence
▶
If included on a consolidated return, attach page 1 of Form 1120 and Form 851.
f
S corporation
g
Employee benefit plan/trust. Plan number, if applicable
▶
Check if:
Section 401(a)
Section 403(b)
Section 457(b)
h
Exempt organization. If organized in the United States, check all applicable boxes.
Section 501(c)
Section 501(c)(3)
Governmental entity
Indian tribe
Other (specify)
▶
i
Disregarded entity. Check if:
LLC
LP
LLP
Other (specify)
▶
j
Nominee applicant (must specify the type of entity/individual for whom the nominee is acting)
▶
8802
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(Rev. 4-2012)
Cat. No. 10003D
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