Form 2063 

(Rev. June 2011) 

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 

OMB No. 1545-0138 

1 Name (please print or type) Social security number or ITIN, if any 

2 U.S. address (number, street, and apt. no. or rural route) City State and ZIP code

3 Complete foreign address 

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

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 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 

By 

(Name and title) 

Area Director’s Stamp 

For Privacy Act and Paperwork Reduction Act Notice, see back of form. 
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? . . . . . . . . . . . . . . . . . . . . . . . . . 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? . . . . . . . . . Yes No

If “Yes,” give the following information: 

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), 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 email us at 

*taxforms@irs.gov. (The asterisk must be included in the address.) Please put 

“Forms Comment” on the subject line. Or you can write to the Internal Revenue 

Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 

Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send the form to 

this address. 

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