(Name and title)

District Director’s Stamp

(District Director of Internal Revenue)

Annual Certificate of Compliance

This certifies thathas satisfied all United States of America income tax obligations with respect to income received or to be received forthe tax year endedByFor Privacy Act and Paperwork Reduction Act Notice, see back of form.

, 19 ,

determined to the extent practicable, based on all informationavailable to me on this date.

OMB No. 1545-0138Expires 4-30-95

(State and ZIP code)

9 Country of destination

Date on which you last arrived in the U.S.

Social security number, if any

(City)

8 Place of departure 7 Date of departure

5 Occupation

Original date of your entry into the U.S.

11 Of what country are you a citizen or subject?

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

YesNo

Department of the TreasuryInternal Revenue Service

3 Complete foreign address1 Name (please type or print)

10 Name of carrier

6 Passport or alien registration card number4 Tax year2 U.S. address (number, street, and apt. no. or rural route)

13 Are you a

resident alien?

Cat. No. 21420Y

12 Of what country are you a resident?

14 15

Form 2063

(Rev. April 1992)
IMPORTANT Please keep this certificate with your passport No Yes

Date

Service Center where you filed return Balance due Tax paid Taxable income

a Was U.S. income tax withheld?b

Did you make any estimated income tax payments? bIf “Yes,” give the following information:

IfU.S. address shown on the income tax return you filed for that year

 “Yes”:

Year

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,

18a19

correct, and complete.

Did you receive any income subject to U.S. income tax during the prior tax year?

17 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?

16 If you are a nonresident alien, state the purpose of your entry into the United States19 Are you liable for filing tax returns or paying taxes to the United States for any prior year not shown on line 18b above?Signature of departing alien

No YesNo YesNo YesNo Yes

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 certain cities, states, and the District of Columbia to carry out their tax laws. If you do not give the information asked for, you may be charged penalties and you may be subject to criminal prosecution. The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is: Recordkeeping, 7 min.; Learning about the law or the form, 2 min.; Preparing the form, 32 min.; Copying, assembling, and sending the form to the IRS, 14 min. If you have comments concerning the accuracy of these time estimates or suggestions for making this form more simple, we would be happy to hear from you. You can write to both the Internal Revenue Service, Washington, DC 20224, Attention: IRS Reports Clearance Officer, T:FP; and the Office of Management and Budget, Paperwork Reduction Project (1545-0138), Washington, DC 20503. DO NOT send this form to either of these offices.