(Name and title)

Area Director’s Stamp

(Field Assistance Area Director)

Internal Revenue Service

Annual Certificate of Compliance

For Privacy Act and Paperwork Reduction Act Notice, see back of form.

This certifies that

By 

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.

OMB No. 1545-0138

Social security number or ITIN, if any

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

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 Department of the Treasury

Internal Revenue Service

3 Complete foreign address

1 Name (please print or type)

8 Date of departure

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

Cat. No. 21420Y

Form 2063

(Rev. September 2006) (IRS Form 2063)

11 Are you a resident alien

of the U.S.? Yes If “No,” enter the country of which you are a resident ©

An employee

Self-employed

City State and ZIP code

4 Tax year 5 While in the U.S., check if you were: 6 Of what country are you a citizen or subject? 7 Passport or alien registration

card number

No
IMPORTANT

Please keep this certificate

with your passport

Yes No

Date

(2) Taxable income (3) Tax paid (4) Balance due

b Was U.S. income tax withheld?

b

c Did you make any estimated income tax payments?

If “Yes,” give the following information:

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

If “Yes”:

(1) 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,

correct, and complete.

c

13a Did you receive any income subject to U.S. income tax during the prior tax year?

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?

14 Are you liable for filing tax returns or paying taxes to the United States for any prior year not shown above?

Signature of departing alien

Yes No

Yes No

Yes No

Yes No

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.

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.

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.

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