OMB Clearance No. 1545-1065
Form
(October 1994)
Additional Questions to be Completed by All Applicants
for Permanent Residence in the United States
9003
This form must accompany your application for permanent residence in the United States
Privacy Act Notice:
Department of the Treasury--Internal Revenue Service
Your response to the following questions will be provided to the Internal Revenue Service pursuant to Sector 6039E
of the Internal Revenue Code of 1986. Use of this information is limited to that needed for tax administration purposes. Failure to provide this
information may result in a $500 penalty unless failure is due to reasonable cause.
On the date of issuance of the Alien Registration Receipt Card, the Immigration and Naturalization Service will send the following information
to the Internal Revenue Service: your name, social security number, address, date of birth, alien identification number, occupation, class of
admission, and answers to IRS Form 9003.
Enter your Social Security Number (SSN) if you have one. If you do not
have an SSN but have used a Taxpayer Identification Number issued to you
by the Internal Revenue Service, enter that number. Otherwise, Write "NONE"
in the space provided; i.e., "
Name ( Last--Surname--Family) (First--Given) (Middle Initial)
Taxpayer Identification Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NONE
Mark appro-
priate column
Yes No
1. Are you self-employed?
2. Have you been in the United States for 183 days or more during any one of the three calendar
years immediately preceding the current calendar year?
3. During the last three years did you receive income from sources in the United States?
4. Did you file a United States Individual Income Tax Return (Forms 1040, 1040A, 1040EZ or
1040NR) in any of the last three years?
If you answered yes to question 4, for which tax year was the last return filed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Mark "yes" if you own and actively operate a business in which you share in the profits other than as
an investor.
Mark "yes" if you spent 183 days or more ( not necessarily consecutive) in the United States during any
calendar years in the United States.
Mark "yes" if you received income paid by individuals or institutions located in the United States.
Income includes, but not limited to, compensation for services provided by you, interest, dividends, rents,
and royalties.
We ask for the information on this form to carry out the Internal Revenue laws of the United States. You
are required to give us the information. We need it to ensure that you are complying with these laws and to allow us to figure and collect
the right amount of tax.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is 5 minutes.
If you have comments concerning the accuracy of this time estimate or suggestions for making this form more simple, we would be happy
to hear from you. You can write to both the Washington, DC 20224. Attention: IRS Reports Clearance Officer,
T:FP, and Paperwork Reduction Project (1545-1065) Washington, DC 20503.
Remarks
Cat. No. 10126D Form2. FOR AUDIT AND STATISTICAL REPORTS
one of the three prior whether or not you worked
Paperwork Reduction Act Notice--
Internal Revenue Service,
Office of Management and Budget. DO NOT send this form
to either of these offices. Instead, return it to the appropriate office of the Department of the Immigration and Naturalization
Service.
9003 (Rev. 1-94)
