1 Name (Please type or print) Social security number, if any OMB No. 1545-0138
; Expires 7-31-92

2 USS. address (number and street or rural route) (City) (State and ZIP code)

3 Complete foreign address

4 Tax year 5 Occupation
6 Passport or alien registration card number 7 Date of departure 8 Place of departure 9 Country of destination
10 Name of carrier 11 Of what country are youa
(a) citizen or subject > (b) resident >

12 Are you a O ves Original date of your Date on which you last

resident alien? [] No entry intothe U.S. > arrived in the U S. >
Department of the Treasury . .
Internal Revenue Service U.S. Departing Alien Income Tax Statement Form 2063

Rev. 8-89)
For a Resident Alien Against Whom a Termination Assessment Has Not Been Made or (Rev. 8-89)

For a Nonresident Alien Having No Taxable Income from United States Sources

Annual Certificate of Compliance

This certifies that

has satisfied all United States of America income tax obliga-
tions with respect to income received or to be received for the
tax year ended .- -, 19.

determined to the extent practicable, based on all information’
available to me on this date.

(District Director of Internal Revenue)

(Name and title)

District Director's Stamp
For Paperwork Reduc

n Act Notice, see back of form.



13 If you are a nonresident alien, state the purpose of your entry into the United States.

14 Did you receive or do yo

IMPORTANT

Please keep this certi
with your passport

u expect to receive any income subject to U.S. income tax for the year shown in item 4 on the other
sideofthisform?. Loe - 1 ves C1 No
If "Yes": (a) Will U.S. income tax be withheld? Le O] yes [1 No
(b) Will you make any estimated income tax payments? . OO yes C1 No
15 (a) Did you receive any income subject to U.S. income tax during the past tax year? . O Yes [] No

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

Year

Taxable income

Tax paid

Balance due

Service Center where you filed return

19

16 Are you liable for filing tax returns or paying taxes to the U.S. for any prior year, not shown in item 15(b) above? . O) ves 1] No

Declaration. —Under penalties of perjury, | declare that | have examined the above statements, and to the best of my knowledge and belief they are true, correct,

and complete.

Signature of departing alien...

Date __.

Paperwork Reduction Act Notice
We ask for this information to carry out the Internal Revenue laws
of the United States. We need it to ensure that taxpayers are
complying with these laws and to allow us to figure and collect the
right amount of tax. You are required to give us this information.

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 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 the Internal
Revenue Service, Washington, DC 20224, Attention: IRS
Reports Clearance Officer, T:FP; or the Office of Management
and Budget, Paperwork Reduction Project (1545-0138),
Washington, DC 20503.