Did you receive or do you expect to receive any income subject to U.S. income tax for the tax year shown on
line 4 on the front of this form? If “Yes,” complete 12b and 12c. If “No,” go to line 13 . . . . . . .
b Was U.S. income tax withheld? . . . . . . . . . . . . . . . . . . . . . . .
c Did you make any estimated income tax payments? . . . . . . . . . . . . . . . . .
Did you receive any income subject to U.S. income tax during the prior tax year? If “Yes,” complete
13b and 13c . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b U.S. address shown on the income tax return you filed for that year:
c (1) Year
(2) Taxable income (3) Tax paid (4) Balance due
14 Are you liable for filing tax returns or paying taxes to the United States for any prior year not shown above? .
Declaration. Under penalties of perjury, I declare that I have examined the above statements, and to the best of my knowledge and belief, they are true,
correct, and complete.
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