Form 8802
(Rev. November 2018)
Department of the Treasury
Internal Revenue Service
Application for United States
Residency Certification
▶
See separate instructions.
OMB No. 1545-1817
Important. For applicable user fee information, see the Instructions for Form 8802.
For IRS use only:
Additional request (see instructions) Foreign claim form attached
Pmt Amt $ .
Deposit Date: / /
Date Pmt Vrfd: / /
Electronic payment confirmation no.
▶
Applicant’s name Applicant’s U.S. taxpayer identification number
If a joint return was filed, spouse’s name (see instructions)
If a separate certification is needed for spouse, check here
▶
If a joint return was filed, spouse’s U.S. taxpayer
identification number
1
Applicant’s name and taxpayer identification number as it should appear on the certification if different from above
2
Applicant’s address during the calendar year for which certification is requested, including country and ZIP or postal code. If a P.O.
box, see instructions.
3a
Mail Form 6166 to the following address:
b
Appointee Information (see instructions):
Appointee Name
▶
CAF No.
▶
Phone No.
▶
( )
Fax No.
▶
( )
4
Applicant is (check appropriate box(es)):
a
Individual. Check all applicable boxes.
U.S. citizen U.S. lawful permanent resident (green card holder) Sole proprietor
Other U.S. resident alien. Type of entry visa
▶
Current nonimmigrant status
▶
and date of change (see instructions)
▶
Dual-status U.S. resident (see instructions). From
▶
to
▶
Partial-year Form 2555 filer (see instructions). U.S. resident from
▶
to
▶
b
Partnership. Check all applicable boxes. U.S. Foreign LLC
c
Trust. Check if: Grantor (U.S.)
Simple Rev. Rul. 81-100 Trust
IRA (for Individual)
Grantor (foreign) Complex Section 584 IRA (for Financial Institution)
d
Estate
e
Corporation. If incorporated in the United States only, go to line 5. Otherwise, continue.
Check if: Section 269B Section 943(e)(1) Section 953(d) Section 1504(d)
Country or countries of incorporation
▶
If a dual-resident corporation, specify other country of residence
▶
If included on a consolidated return, attach page 1 of Form 1120 and Form 851.
f
S corporation
g
Employee benefit plan/trust. Plan number, if applicable
▶
Check if: Section 401(a) Section 403(b)
Section 457(b)
h
Exempt organization. If organized in the United States, check all applicable boxes.
Section 501(c) Section 501(c)(3) Governmental entity
Indian tribe Other (specify)
▶
i
Disregarded entity. Check if: LLC LP LLP Other (specify)
▶
j
Nominee applicant (must specify the type of entity/individual for whom the nominee is acting)
▶
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 10003D
Form 8802 (Rev. 11-2018)
