Form 8854
Department of the Treasury
Internal Revenue Service
Initial and Annual Expatriation Statement
For calendar year 2019 or other tax year beginning , 2019, and ending , 20
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Go to www.irs.gov/Form8854 for instructions and the latest information.
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Please print or type.
OMB No. 1545-0074
2019
Attachment
Sequence No.
112
Name Identifying number (see instructions)
Part I General Information. For all filers.
1
Mailing address and telephone number where you can be reached after expatriation
2
Address of principal foreign residence (if different from line 1)
3
Country of tax residence (if different from line 2)
4 Check the box that applies. See instructions.
Initial expatriation statement for persons who expatriated in 2019. Complete Part II.
Annual expatriation statement for persons who expatriated before 2019. Complete Part III.
5 Date of expatriation under section 877A(g)(3) for expatriating citizens and long-term residents. See instructions.
Citizen
Long-term resident
Long-term resident with dual residency in a treaty country. Date commencing to be treated, for tax purposes, as a
resident of the treaty country
6 List all countries (other than the United States) of which you are a citizen.
a
Name of country
b
Date you became a citizen of each country listed in line 6a
7 How you became a U.S. citizen
By birth By naturalization
8
Date you became a U.S. lawful permanent resident
Part II Initial Expatriation Statement for Persons Who Expatriated in 2019
Section A Expatriation Information
1 Enter your U.S. income tax liability (after foreign tax credits) for the 5 tax years ending before the date of expatriation.
1st Year
Before Expatriation
$
2nd Year
Before Expatriation
$
3rd Year
Before Expatriation
$
4th Year
Before Expatriation
$
5th Year
Before Expatriation
$
2 Enter your net worth on the date of your expatriation for tax purposes . . . . . . . . . .
$
3 Did you become at birth a U.S. citizen and a citizen of another country, and do you continue to be a citizen
of, and taxed as a resident of, that other country? . . . . . . . . . . . . . . . . . . .
Yes No
4 If you answered “Yes” to question 3, have you been a resident of the United States for not more than 10 of
the last 15 tax years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
5 Were you under age 18
1
/2 on the date you expatriated and have you been a U.S. resident for not more than
10 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
6 Do you certify under penalties of perjury that you have complied with all of your tax obligations for the 5
preceding tax years? See instructions . . . . . . . . . . . . . . . . . . . . . . .
Yes No
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 24126N
Form 8854 (2019)