Usa Income Tax Return Page 3
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4USA INCOME TAX RETURN
FOREIGN INCOME AND DEDUCTIONS
FOREIGN SOURCE INCOME AND EXPENSES INFORMATION:
Do you have foreign Self-Employment Income? Yes
No
Provide your foreign employer’s full name and address (if you are employed in a foreign country).
If more than 1 employer, attach additional statement.
Employer Name
______________________________________________________________________________________________________________
Employer Address
__________________________________________________________________________________
City
_____________________
Your employer is: a foreign entity
a foreign affiliate of a US company
a US Company
Do you have statements to support foreign income and foreign taxes paid? Yes
No
If you have such statements, please send a copy of your payment summary up to December 31st or to the date you stopped working (whichever applies).
Do you have a foreign interest bearing bank account? Yes
No
If yes, provide us with a statement showing your accrued interest by December 31st
Did you receive foreign pension or social security payments? Yes
No
If yes, provide us with statements showing your pension income by December 31st
Did you receive any other foreign income not expressly mentioned? Yes
No
If yes, describe income received and taxes paid here:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
What was your housing arrangement while outside the USA?
Rented Accommodation Yes
No
If yes give the amount of rent paid per month:
____________________________
Currency:
__________
Own Accommodation Yes
No
Employer provided accommodation Yes
No
Other: Give explanation here
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
I (We, if filing jointly) acknowledge that the above information provided by me/us is true and accurate to the best of my/our knowledge. I hereby
relieve Taxback Inc, its agents and affiliates, from any liability whatsoever, regarding the preparation of this/ these tax returns, and I (we) guar-
antee payment of the preparation fee and any related charges in accordance to the Taxback Inc, Terms and Conditions.
Print Name
mm
dd
yyyy
Date
_______ / _______ / _________
Primary Taxpayer’s Signature
Print Name
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dd
yyyy
Spouse’s Signature
Date
_______ / _______ / _________
, IDA Business & Technology Park, Ring Road, Kilkenny, Ireland
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