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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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signature
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