Form 2063 U.S. Departing Alien Income Tax Statement

2
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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 2063, PAGE 1 of 2
MARGINS: TOP 6mm (1⁄ 4"), CENTER SIDES.
PRINTS: HEAD to FOOT
PAPER: WHITE LEDGER, SUB. 32.
INK: BLACK
1
FLAT SIZE: 279mm (11") 3 108mm (4 ⁄ 4")
PERFORATE: VERTICALLY 92mm (35⁄ 8") FROM RIGHT EDGE OF FORM.
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Date

Form 2063
(Rev. September 2006)
Department of the Treasury
Internal Revenue Service

Action

Date

Signature

O.K. to print
Revised proofs
requested

Annual Certificate of Compliance

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

1

Name (please print or type)

2

U.S. address (number, street, and apt. no. or rural route)

3

Complete foreign address

City

(IRS Form 2063)

OMB No. 1545-0138

Social security number or ITIN, if any

This certifies that

State and ZIP code

has satisfied all United States of America income tax obligations 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
4

Tax year

5

While in the U.S., check if you were:

6 Of what country are you a citizen or subject?

An employee

By

Self-employed
8

11

Date of departure

Are you a resident alien
of the U.S.?

9

7 Passport or alien registration
card number
(Name and title)

Original date of your entry into the U.S. 10 Date on which you last arrived in the U.S.

Yes

No

If “No,” enter the country of which you are a resident ©

Area Director’s Stamp
For Privacy Act and Paperwork Reduction Act Notice, see back of form.

Cat. No. 21420Y

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 2063, PAGE 2 of 2
MARGINS: TOP 6mm (1⁄ 4 "), CENTER SIDES.
PRINTS: HEAD to FOOT
PAPER: WHITE LEDGER, SUB. 32.
INK: BLACK
1
FLAT SIZE: 279mm (11") 3 108mm (4 ⁄ 4 ")
PERFORATE: VERTICALLY 92mm (35⁄ 8 ") FROM RIGHT EDGE OF FORM.
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

12a

Did you receive or do you expect to receive any income subject to U.S. income tax for the year shown on line 4
on the front of this form?

IMPORTANT
Yes

No

If “Yes”:
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?

b

If “Yes,” give the following information:
U.S. address shown on the income tax return you filed for that year:

c

(1) Year

14

(2) Taxable income

Yes

(3) Tax paid

No

(4) Balance due

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

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), 6851, and
their regulations require that you give us the information. Routine uses of
this information include giving it to the Department of Justice for civil and
criminal litigation and to cities, states, and the District of Columbia 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 the information asked for, you may be
charged penalties and you may be subject to criminal prosecution.
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 write to the Internal Revenue Service, Tax Products
Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave.
NW, IR-6406, Washington, DC 20224. Do not send the form to this
address.