Form 2063
(Rev. September 2013)
Department of the Treasury
Internal Revenue Service
U.S. Departing Alien Income Tax Statement
For a Resident Alien Against Whom a Termination Assessment Has Not Been Made or
for a Nonresident Alien Having No Taxable Income From United States Sources
Information about Form 2063 is available at www.irs.gov/form2063.
OMB No. 1545-0138
1 Name (please print or type)
Social security number or ITIN, if any
2 U.S. address (number, street, apt. no. or rural route, city, state, and ZIP code)
3 Foreign address (street address, city or town, state or province, country, and ZIP or foreign postal code)
4 Tax year
5 While in the U.S., check if you were:
An employee
Self-employed
6 Of what country are you a citizen or subject? 7 Passport or alien registration
card number
8 Date of departure
(MM/DD/YYYY)
9
Original date of your entry into the U.S.
(MM/DD/YYYY)
10 Date on which you last arrived in the U.S. (MM/DD/YYYY)
11 Are you a resident alien
of the U.S.?
Yes No
If “No,” enter the country of which you are a resident
Cat. No. 21420Y
Annual Certificate of Compliance
(IRS Form 2063)
This certifies that
has satisfied all United States of America income tax obliga-
tions with respect to income received or to be received for
the tax year ended
, ,
determined to the extent practicable, based on all information
available to me on this date.
(Field Assistance Area Director)
Internal Revenue Service
By
(Name and title)
Area Director’s Stamp
For Privacy Act and Paperwork Reduction Act Notice, see back of form.
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12a
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 . . . . . . .
Yes No
b Was U.S. income tax withheld? . . . . . . . . . . . . . . . . . . . . . . .
Yes No
c Did you make any estimated income tax payments? . . . . . . . . . . . . . . . . .
Yes No
13a
Did you receive any income subject to U.S. income tax during the prior tax year? If “Yes,” complete
13b and 13c . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
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? .
Yes No
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.
Sign
Here
Signature of departing alien Date
IMPORTANT
Please keep this certificate
with your passport
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on
this form to carry out the Internal Revenue laws of the United States. Internal
Revenue Code sections 6001, 6011, 6012(a), 6109, and 6851, and their regulations
require that you give us the information, including your identifying number(s).
Routine uses of this information include giving it to the Department of Justice for
civil and criminal litigation and to cities, states, the District of Columbia, and U.S.
commonwealths or possessions to carry out their tax laws. We may also disclose
this information to other countries under a tax treaty, to federal and state agencies
to enforce federal nontax criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism. If you do not give us the information
asked for, or provide false or incomplete information, you may be subject to
penalties.
You are not required to provide the information requested on a form that
is subject to the Paperwork Reduction Act unless the form displays a valid
OMB control number. Books or records relating to a form or its instructions
must be retained as long as their contents may become material in the
administration of any Internal Revenue law. Generally, tax returns and
return information are confidential, as required by Code section 6103.
The time needed to complete and file this form will vary depending on individual
circumstances. The estimated average time is: Recordkeeping, 6 min.; Learning
about the law or the form, 3 min.; Preparing the form, 26 min.; Copying,
assembling, and sending the form to the IRS, 13 min. If you have comments
concerning the accuracy of these time estimates or suggestions for making this
form simpler, we would be happy to hear from you. You can send us comments
from www.irs.gov/formspubs/. Click on “More Information” and then on “Comment
on Tax Forms and Publications.” You can write to the Internal Revenue Service,
Tax Forms and Publications, SE:W:CAR:MP:TFP, 1111 Constitution Ave. NW,
IR-6526, Washington, DC 20224. Do not send your tax return or this form to this
address.
click to sign
signature
click to edit
dd mmm yyyy
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