IRS U.S. Departing Alien Income Tax Return
This is an IRS departing alien income tax return. The form provided here is a 2001 Form 1040-C and is simply a sample of what you will need to complete. Please be aware the tax returns differ every year.
U.S. Departing Alien Income Tax Return
Form 1040-C
For tax period or year beginning ___________, _______, and ending ______________, ________.
Department of the Treasury
Internal Revenue Service
OMB No. 1545-0086
Your first name and initial ________________________________
Last name __________________________
Your identifying number (see page 2) ________ ________ _________
If a joint return, spouse's first name and initial (see instructions) ________________________________
Last name __________________________
Spouse's identifying number ________ ________ _________
U.S. address (number, street, and apt. no. or rural route) ___________________________
City ________________________________
State ______________________________
ZIP code _____________________
Passport or alien registration card number
Your number ____________________________
Spouse's number ____________________________
Original date of your entry into the U.S. __________________________
Date of departure __________________________
Complete foreign address _________________________________________
Date on which you last arrived in the U.S. __________________
Of what country are you a citizen or subject? __________________________________
Of what country are you a resident? __________________________________
A Is your employer willing to furnish a letter guaranteeing that the tax will be paid?
___Yes ___ No
If "Yes," attach the letter and leave the remainder of this form blank except for the signature area on page 2.
Caution: Form 1040-C is not a final income tax return. You must file a final return on the correct form after your tax year ends.
See Final Return Required on page 1 of the instructions.
Part I Explanation of Status--Resident or Nonresident Alien
1 Check the applicable box or boxes below:
Note: A nonresident alien who has income from real property may elect to treat this income as effectively connected income.
Gain or loss on the disposition of a U.S. real property interest by a nonresident alien is effectively connected income or loss. For details, see the 2000 Form 1040NR instructions or Pub. 519, U.S. Tax Guide for Aliens.
___ Group I--Resident alien.
___ Group II--Nonresident alien with income effectively connected with a U.S. trade or business.
___ Group III--Nonresident alien with income not effectively connected with a U.S. trade or business.
2 Kind of trade or business or occupation in the United States _________________________
3 Visa number and class under which you were last admitted to the United States _________________________
4 Do you have a permit to reenter the United States? ___Yes ___ No
If "Yes," enter the expiration date _______________
5 Have you signed a waiver of rights, privileges, exemptions, and immunities as described under Exceptions starting on page 1 of the instructions? ___Yes ___ No
If "Yes," enter the date signed __________________
6 If you were employed in the United States, did you file Form 1078, Certificate of Alien Claiming Residence in the United States, or Form W-9, Request for Taxpayer Identification Number and Certification? ___Yes ___ No
7 Have you applied for U.S. citizenship? ___Yes ___ No
8 If you filed income tax returns in the United States, give the following information for 2000:
a Your U.S. address shown on return _______________________________________________
b Taxable income reported $___________
c Tax paid $__________
d Balance due $____________
9 Do you know of any current charges against you concerning your U.S. taxes for any tax period? ___Yes ___ No
10 Do you plan to return to the United States? ___Yes ___ No
If "Yes," complete lines 11 through 13 below.
11 Are your spouse and any children remaining in the United States? ___Yes ___ No
12 Show the approximate value and location in the United States of any property held by you:
a Real property $_____________ (Value); __________________________________ (Location)
b Stocks and bonds $_____________ (Value); __________________________________ (Location)
c Cash $_____________ (Value); __________________________________ (Location)
d Other (specify) _______________ $__________ (Value); _____________________________ (Location)
13 If you will not return before (a) the due date for filing a final U.S. income tax return for the current year or (b) the due date for filing a final U.S. income tax return for the preceding year, what arrangements have you made to file the final income tax return(s) and pay the tax(es)? ____________________________________________
Part II Exemptions
Group I--If you are a resident alien, you may claim the same exemptions allowed U.S. citizens on Form 1040.
Group II--If you are a nonresident alien with income effectively connected with a U.S. business, you may claim one exemption. Residents of Canada, India, Mexico, Japan, the Republic of Korea, or U.S. nationals (American Samoans), see page 3 of the instructions.
Group III--If you are a nonresident alien with income not effectively connected with a U.S. business, do not claim any exemptions from that income.
14a ____ Yourself b ____ Spouse
Caution: If your parent (or someone else) can claim you as a dependent on his or her 2001 tax return, do not check box 14a.
No. of boxes checked on 14a and 14b . . . _______
No. of your children on 14c who:
● lived with you . . ________
● did not live with you due to divorce or separation . . _________
Dependents on 14c not entered above _______
c Dependents:
(1) First name ___________________________ Last name ___________________________
(2) Dependent's SSN or ITIN ___________________________
(3) Dependent's relationship to you ___________________________
(4) Check if qualifying child for child tax credit _______
d Total number of exemptions claimed
Add numbers entered on lines above ___________
Part III Figuring Your Income Tax
15 Total income (from page 3, Schedule A, line 4, column (d) or (e)) . . . 15 ________
16 Adjustments. See page 3 of the instructions and attach appropriate form or statement . . . 16 ________
17 Adjusted gross income. Subtract line 16 from line 15 17 _______
18 Tax (from page 4, Schedule D, line 6 or 12, whichever applies) 18 _______
19 Credits. See page 3 of the instructions and attach appropriate form or statement 19 _______
20 Subtract line 19 from line 18. If zero or less, enter -0- 20 _______
21 Other taxes. See page 3 of the instructions and attach appropriate form 21 _______
22 Tax for Group I or II. Add lines 20 and 21 22 _______
23 Total income (from page 3, Schedule A, line 4, column (f)) 23 _______ _______
24 Tax (30% of line 23). If less than 30%, attach statement showing computation 24 _______
25 Total tax. Add lines 22 and 24 25 _______
26 U.S. income tax paid or withheld at source (from page 3, Schedule A, line 4, column (c), or withheld from Forms W-2, W-2G, 1099-R, etc.) 26 _______
27 Estimated U.S. income tax paid 27 _______
28 Other payments (specify) _______________________ 28 _______
29 Total payments. Add lines 26 through 28 29 _______
30 If line 25 is more than line 29, subtract line 29 from line 25. This is the amount you owe . . 30 _______
31 If line 29 is more than line 25, subtract line 25 from line 29. This is the amount you overpaid. Any overpayment of tax will be refunded only when you file your final return for the tax year 31 _______
Note: Your tax liability on your final return may be different from the figure you entered on line 25 above.
Sign Here Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
_____________________________ (Signature) _______________ (Date) (A return made by an agent must be accompanied by a power of attorney.)
Spouse's signature ____________________________ _______________ (Date) (If filing jointly, both must sign even if only one had income.)
Paid Preparer's Use Only
Preparer's Signature _____________________ _________ (Date)
Check if self-employed ___
Preparer's SSN or PTIN _________
Firm's name (or yours if self-employed) _________________________________________
Address ___________________________________
ZIP code ______________________________
EIN ________________
Phone No. ___ _______________
Certificate of Compliance
This certifies that the above individual(s) has satisfied all the requirements of the Internal Revenue Code and the Internal Revenue Regulations relating to departing aliens according to all information available to me at this date. This certificate is effective for the tax period
beginning ____________ 2001, and ending __________ or the tax year ended _____________ ________
___________________________________ (Field Assistance Area Director)
Internal Revenue Service
Date ______________________
By _____________________________________ (Name)
________________________________________ (Title)
Schedule A Income (Do not include exempt income on lines 1 through 4.)
1 (a) Payer of income __________________________
(b) Type of income (such as salary, wages, taxable interest, dividends, rents, alimony received, etc.) ___________________________
(c) Amount of U.S. income tax paid or withheld at source ________________
(d) Resident alien income ________________
Nonresident alien income
(e) Effectively connected with a U.S. trade or business* __________________
(f) Not effectively connected with a U.S. trade or business** __________________
2 Net gain, if any, from Schedule D (Form 1040) 2 __________________
3 Net gain, if any, from Schedule B, line 2 3 _____________________
4 Totals 4 _____________________
5 Tax-exempt interest income. Do not include on line 4 5 ______________________
*Enter in column (e): (1) salary and wages as shown on Form W-2; (2) net income from the operation of a business from separate Schedule C (Form 1040), or other appropriate business schedule; and (3) any other income effectively connected with a U.S. trade or business.
** Including alimony received.
Include any U.S. income tax that was paid or withheld on income in column (c), lines 1 through 3.
Schedule B Gains and Losses From Sales or Exchanges of Nonresidents' Property Not Effectively Connected With a U.S. Trade or Business (Capital gains and income other than capital gains)
You must complete this schedule if you are a nonresident alien with gains from the sale or exchange of property (except U.S. real property interests) from sources in the United States that are not effectively connected with a U.S. trade or business. Include any U.S. income tax that was paid or withheld on these gains on Schedule A, column (c), line 3.
1 (a) Description of property (If necessary, attach statement of descriptive details not shown below.) __________________________________
(b) Date acquired (mo., day, yr.) __________________________
(c) Date sold (mo., day, yr.) __________________________
(d) Sales price _________________________
(e) Cost or other basis ______________________
(f) Gain or (loss) subtract (e) from (d) ________________
2 Net gain. Enter on Schedule A, line 3, column (f) 2 _______________
Schedule C Itemized Deductions
● If you are a resident alien reporting income on Schedule A, column (d), you may claim the same deductions allowable on Schedule A (Form 1040).
● If you are a nonresident alien reporting income on Schedule A, column (e), you may claim only deductions that are connected to U.S. trade or business income and not deducted elsewhere. See Schedule A (Form 1040NR). However, casualty or theft losses and charitable contributions do not have to be related to U.S. trade or business income. You should file Form 4684, Casualties and Thefts, to support casualty or theft loses shown below.
● If you are a nonresident alien reporting income on Schedule A, column (f), do not claim any deductions related to that income.
1 (a) Type of deduction (such as interest, taxes, contributions, etc.) ____________________
(b) Amount of deduction _______________
(c) Type of deduction (such as interest, taxes, contributions, etc.) ____________________
(d) Amount of deduction ______________
2 Total itemized deductions. Add the amounts in columns (b) and (d) of line 1. Enter the total here and on Schedule D, line 2 or line 8, whichever applies. Exception. If the amount on Form 1040-C, line 17, is over $132,950 ($66,475 if married filing separately), see the instructions starting on page 4 for the amount to enter 2 _____________
Schedule D Tax Computation
Tax for Resident Alien--Group I Only (For description of groups, see Form 1040-C, line 1.)
1 Enter amount from Form 1040-C, line 17 1 ____________
2 If you itemize deductions, enter amount from page 3, Schedule C, line 2 (to the extent they are allowable on Schedule A (Form 1040)). If you do not plan to itemize deductions, enter your standard deduction. See Standard Deduction (Group 1 only) on page 5 of the instructions 2 ______________
3 Subtract line 2 from line 1 3 _________________
4 Exemptions. If line 1 above is $99,725 or less, multiply $2,900 by the total number of exemptions claimed on Form 1040-C, line 14d. If line 1 above is over $99,725, see the worksheet on page 6 of the instructions for the amount to enter 4 ____________
5 Taxable income. Subtract line 4 from line 3 5 _______________
6 Tax. Figure your tax on the amount on line 5 by using the 2001 Tax Rate Schedules on page 6 of the instructions. Include in the total any tax from Form 4972, Form 6251, and Form 8814. Enter the tax here and on Form 1040-C, line 18 6 ______________
Tax for Nonresident Alien With Income Effectively Connected With a U.S. Trade or Business--Group II Only
7 Enter amount from Form 1040-C, line 17 7 ________________
8 Enter itemized deductions from page 3, Schedule C, line 2 (to the extent they are allowable on Schedule A (Form 1040NR)) 8 _______________
9 Subtract line 8 from line 7 9 ________________
10 Exemptions. If line 7 above is $99,725 or less, multiply $2,900 by the total number of exemptions claimed on Form 1040-C, line 14d. If line 7 above is over $99,725, see the worksheet on page 6 of the instructions for the amount to enter 10 __________________
11 Taxable income. Subtract line 10 from line 9 11 _________________
12 Tax. Figure your tax on the amount on line 11 by using the 2001 Tax Rate Schedules on page 6 of the instructions. Include in the total any tax from Form 4972, Form 6251, and Form 8814. Enter the tax here and on Form 1040-C, line 18 12 _______________________