Form 1040-C
Department of the Treasury
Internal Revenue Service
U.S. Departing Alien Income Tax Return
For tax period or year beginning , 2018, and ending ,
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Go to www.irs.gov/Form1040C for instructions and the latest information.
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File original and one copy.
OMB No. 1545-0074
2018
Print
or
type
Your first name and initial Last name Your social security number
If a joint return, spouse’s first name and initial (see instructions) Last name Spouse’s identifying number
U.S. address (number, street, and apt. no. or rural route)
City, state, and ZIP code
Passport or alien registration card number
Your number Spouse’s number
Date on which you first arrived in the U.S.
Date of departure
Complete foreign address Date on which you last arrived in the U.S.
Of what country are you a citizen or national? Of what country are you a resident for tax purposes?
Caution: Form 1040-C is not a final income tax return. You must file a final return on the correct form after your tax year ends.
See Final Return Required on the instructions.
Part I Explanation of Status—Resident or Nonresident Alien
1
Check the applicable box or boxes. Note: A nonresident alien who has income from U.S. real property may elect to treat this income
as effectively connected income. Gain or loss on the disposition of a U.S. real property interest by a nonresident alien is effectively
connected income or loss. For details, see the 2017 Form 1040NR instructions or Pub. 519, U.S. Tax Guide for Aliens.
Group I—Resident alien.
Group II—Nonresident alien with income effectively connected with a U.S. trade or business.
Group III—Nonresident alien with income not effectively connected with a U.S. trade or business.
2
Type of trade or business or occupation in the United States
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3
Visa number and class under which you were last admitted to the United States
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4 Do you have a permit to reenter the United States? . . . . . . . . . . . . . . . . . . . Yes No
If “Yes,” enter the expiration date
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5 Have you signed a waiver of rights, privileges, exemptions, and immunities as described under Exceptions
in the instructions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If “Yes,” enter the date signed
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6
During your stay in the United States did you furnish either of the following forms to a withholding agent:
Form W-9, Request for Taxpayer Identification Number and Certification, or Form 1078, Certificate of Alien
Claiming Residence in the United States? . . . . . . . . . . . . . . . . . . . . . . Yes No
7 a Have you applied for U.S. citizenship? . . . . . . . . . . . . . . . . . . . . . . .
Yes No
b
Have you applied for, or taken other affirmative steps to apply for, lawful permanent resident status (green
card holder) in the United States, or do you have an application pending to change your status to that of a
lawful permanent resident of the United States? . . . . . . . . . . . . . . . . . . . .
Yes No
8 If you filed income tax returns in the United States, give the following information for 2017.
a
Type of return filed (for example, Form 1040, 1040NR, etc.)
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b
Your U.S. address, if any, shown on return
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c
Taxable income reported
$ d
Total tax payments
$ e Balance due $
9 Do you know of any current charges against you concerning your U.S. taxes for any tax period? . . . .
Yes No
10 Do you plan to return to the United States? . . . . . . . . . . . . . . . . . . . . . .
Yes No
If “Yes,” complete lines 11 through 13 below .
11 Are your spouse and any children remaining in the United States? . . . . . . . . . . . . . .
Yes No
12 Show the approximate value and location in the United States of any property held by you.
Value Location
a Real property
{
. . . . . . . . $ ;
. . . . . . . . $ ;
b Stocks and bonds . . . . . . . . $ ;
c Cash . . . . . . . . . . . . $ ;
d
Other (specify)
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$ ;
13
If you will not return to the United States before the due date for filing a final U.S. income tax return for the current year or the
due date for filing a final U.S. income tax return for the preceding year, what arrangements have you made to file the final
income tax return(s) and pay the tax(es)?
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For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see the instructions.
Cat. No. 11310F
Form 1040-C (2018)
