Fillable F9210 Form 9210 (Rev. 7-2015)

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F9210 Form 9210 (Rev. 7-2015)

On average this form takes 15 minutes to complete

The F9210 Form 9210 (Rev. 7-2015) form is 2 pages long and contains:

  • 1 signature
  • 33 check-boxes
  • 42 other fields

Country of origin: US
File type: PDF

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The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

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Catalog Number 11842U www.irs.gov
Form
9210 (Rev. 7-2015)
Form 9210
(July 2015)
Department of the Treasury - Internal Revenue Service
Alien Status Questionnaire
Taxpayer's name and address
In reply refer to:
Tax year
Last four digits of Social Security Number
Principal place of employment
Furnish the following information concerning your alien status in the United States during the above tax year.
1. Name of country of which you are now a citizen or subject
2. Name of country in which you claimed residence during the above tax year
3. Visa Type (Letter and Number) under which you first entered the United States
4. List all other Visa Types which you held (Letter and Number), and dates obtained, if different than Visa shown in item 3, including Visa
currently held
Visa Type Date Obtained
5. For what reason did you come to the United States
Education Work Vacation Teaching Foreign government employee Other
If Other, explain
6. What was the date of your initial arrival in the United States 7. How long do you expect to remain in the United States
8. Did you change your original intention about the length of your stay
Yes No
If Yes, explain
9. Did you ever apply for and/or have been granted lawful permanent residence in the
United States (hold a Green Card)
Yes No
If Yes, explain
10. Did your family accompany you to the United States
Yes No Not married
If Yes, what type of visa did your family enter the United States on (Number and Letter)
Did your spouse, or any other member of your family, work in the United States
Yes No
If Yes, please furnish us a copy of their U.S. Federal income tax return
Page 2
Catalog Number 11842U www.irs.gov
Form
9210 (Rev. 7-2015)
11. Were you employed in the United States
Yes No
If Yes, please complete the following
a. Were there any restrictions on the length of your employment
Yes No
b. If Yes to a. above, please state what the restrictions were
c. Name and address of employer
12. Did you file a foreign income tax return with a foreign country while you were a
resident in the United States
Yes No
If Yes, please provide us with a copy of the foreign tax return
13. Are you employed in the United States by the same employer for whom you worked
in the foreign country prior to your move to the United States
Yes No Not employed
14. Did you leave the United States after you first arrived
Yes No Did not leave
If Yes, please complete the following
Did you intend to return
Yes No
When did you intend to return?
Yes No
What was the expiration date (including any extensions) of the permit
Did you obtain a reentry permit
Did you give up your United States residence when you departed the United States
Yes No
What was the date of your final departure from the United States
How much income did you earn outside the United States in the year of your final departure
15. Please provide us in the space below all the dates of your arrival in, and departures from, the United States from the date you first
arrived in the United States, and the purpose of each departure from the United States
Arrival Date Departure Date Purpose
Remarks
Certification: Under penalty of perjury, I declare that I have examined this statement and, to the best of my knowledge and belief, it is
true, correct, and complete
Taxpayer's signature Date
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F9210 Form 9210 (Rev. 7-2015)

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Completed 7 June 2020

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