Part III

U.S. Nonresident Alien Income Tax Declaration

for Magnetic Media Filing 8453-NR

Department of the Treasury

Internal Revenue Service

For the year January 1–December 31, 1995

© See instructions on back.

Taxpayer’s first name and initial Last name Identifying or social security number

Tax Return Information (Whole dollars only)

1 Total effectively connected income (Form 1040NR, line 23) 1

2 Total tax (Form 1040NR, line 52) 2

3 Total payments (Form 1040NR, line 61). If any is from Form(s) 1099, check here © 3

4 Refund (Form 1040NR, line 63) 4

5 5 Amount you owe (Form 1040NR, line 65)

Direct Deposit of Refund (Optional—See instructions.)

6 Name of financial institution and, if applicable, branch name

7 Routing transit number (RTN)

The first two numbers of the RTN must

be 01 through 12 or 21 through 32.

8 Depositor account number (DAN)

10 Ownership of account: Self Self and Spouse

Declaration of Taxpayer (Sign only if Part I is completed.)

Under penalties of perjury, I declare that the information I have given my magnetic media return originator (MMRO) and the amounts in Part I above

(or the amounts on the attached listing) agree with the amounts on the corresponding lines of the magnetic media portion of my 1995 Federal

income tax return. To the best of my knowledge and belief, my return is true, correct, and complete. I consent to my MMRO sending my return,

this declaration, and accompanying schedules and statements to the Internal Revenue Service (IRS). I also consent to the IRS sending my MMRO

an acknowledgment of receipt of transmission and an indication of whether or not my return is accepted, and, if rejected, the reason(s) for the

rejection.

Please

Sign Here Your signature Date

Declaration of Magnetic Media Return Originator (MMRO) and Paid Preparer (See instructions.)

Date Your social security number

Check if selfemployedMMRO’s

MMRO’s signature

Use Only Firm’s name (or

yours if self-employed)

and address

EIN

ZIP code

Under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the

best of my knowledge and belief, they are true, correct, and complete. This declaration is based on all information of which I have any knowledge.

Date Preparer’s social security no.

Preparer’s

signature Paid

Preparer’s

Use Only

EIN

ZIP code

Cat. No. 13115A Form 8453-NR (1995)

Part I

©

I declare that I have reviewed the above taxpayer’s return and that the entries on Form 8453-NR are complete and correct to the best of my

knowledge. If I am only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data on the

return. If Part II is completed, I declare that I have verified the taxpayer’s proof of account and it agrees with the name shown on this form. The

taxpayer will have signed this form before I submit the return. I will give the taxpayer a copy of all forms and information to be filed with the IRS,

and have followed all other requirements in Procedures for Magnetic Media Filing of U.S. Nonresident Alien Income Tax Returns, Forms 1040NR,

for Tax Year 1995. If I am also the paid preparer, under penalties of perjury I declare that I have examined the above taxpayer’s return and

accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. This declaration is

based on all information of which I have any knowledge.

Part IV

©

©

Firm’s name (or

yours if self-employed)

and address

Check if © self-employed

©

OMB No. 1545-1274

For Paperwork Reduction Act Notice, see instructions.

Part II

I consent that my refund be directly deposited as designated in Part II, and declare that the information on lines 6 through 10 is correct.

If I have filed a balance-due return, I understand that if the IRS does not receive full and timely payment of my tax liability, I will remain liable for

the tax liability and all applicable interest and penalties. Form

11

I do not want direct deposit of my refund or am not receiving a refund.

Check if

also paid

preparer

9 Type of account: Checking Savings
Form 8453-NR (1995) Page 2

Purpose of Form

Use Form 8453-NR to:

● Authenticate the magnetic media portion of Form 1040NR,

U.S. Nonresident Alien Income Tax Return,

● Send any accompanying paper schedules, statements, and

magnetic media,

For accounts payable through a financial institution other than

the one at which the account is located, the taxpayer must

provide a document, such as an account statement or account

identification card, showing the RTN of the bank or institution

where the account is located. A deposit slip should not be used

to verify the RTN and DAN because it can contain internal

routing numbers that are not part of the RTN. If there is any

doubt about the correct RTN, the taxpayer should contact the

financial institution and ask for the correct RTN for direct deposit

(Electronic Funds Transfers).

● Authorize the magnetic media return originator (MMRO) to

transmit via a third-party transmitter, and

● Provide the taxpayer’s consent to directly deposit any

overpayment into an account of a U.S. financial institution

located in the United States.

Who Must File

Every nonresident alien filing a 1995 Form 1040NR via magnetic

media must file a signed 1995 Form 8453-NR.

Note: Some financial institutions may not accept direct deposits

into accounts that are payable through another bank or financial

institution, including credit unions. Also, the financial institution

must be a U.S. financial institution located in the United States.

The IRS cannot make a direct deposit to a foreign bank or a

foreign branch of a U.S. bank.

Signature for Multiple-Return Filing

A single signature may be used for a multiple-return filing by a

person authorized to sign each return. If you are filing more than

one return for which only one signature is provided, write “See

attached Multiple-Return Information Listing” in the space

provided for the taxpayer’s name. You must also attach a

Multiple-Return Information Listing according to the instructions

given in the Procedures for Magnetic Media Filing of U.S.

Nonresident Alien Income Tax Returns, Forms 1040NR, for Tax

Year 1995. The information listing must include the name control

for each taxpayer, taxpayer identification number (TIN), and the

information requested on lines 1 through 5 of Form 8453-NR for

each return. An incorrect or missing TIN may delay any refund.

Line 10. The account designated to receive the direct deposit

must be in the taxpayer’s name. If the taxpayer’s filing status on

Form 1040NR is married filing separately, the account can be in

the taxpayer’s name or in both spouses’ names.

Part III—Declaration of Taxpayer

An income tax return transmitted on magnetic media will not be

considered complete, and therefore filed, unless and until a

Form 8453-NR signed by the taxpayer is received by the IRS.

When To File

Returns filed on magnetic media are due the same dates as

Forms 1040NR filed on paper. The transmitter must send the

signed Form(s) 8453-NR in the same package with the

corresponding tape or diskette.

If the MMRO makes changes to the magnetic media return

after Form 8453-NR has been signed by the taxpayer but before

it is transmitted, the MMRO must have the taxpayer complete

and sign a corrected Form 8453-NR if either of the following

applies:

Where To File

● The total effectively connected income on line 1 differs from

the amount on the magnetic media portion of the return by more

than $25, or

Send Form 8453-NR to:

Internal Revenue Service

Philadelphia Service Center

Attention: DP: 115

11601 Roosevelt Blvd.

Philadelphia, PA 19154

● The total tax on line 2, the refund on line 4, or the amount

owed on line 5 differs from the amount on the magnetic media

portion of the return by more than $7.

Part IV—Declaration of Magnetic Media

Return Originator (MMRO) and Paid

Preparer

Part II—Direct Deposit of Refund

Taxpayers can elect to have their refund directly deposited by

completing Part II. But to do so, they must provide proof of

account ownership to their MMRO. Acceptable proof is a check,

Line 7. The RTN must be nine digits. If the RTN does not begin

with 01 through 12 or 21 through 32, the direct deposit will be

rejected.

Line 8. The DAN can be up to 17 alphanumeric characters.

Include hyphens but omit spaces and special symbols. If fewer

than 17 characters, enter the number from left to right and leave

the unused boxes blank.

Refunds. After the IRS has accepted the return, the refund

should be issued within 21 days. However, some refunds may

be delayed because of compliance reviews to ensure that

returns are accurate.

Paperwork Reduction Act Notice

We ask for the information on this form to carry out the Internal

Revenue laws of the United States. You are required to give us

the information. We need it to ensure that you are complying

with these laws and to allow us to figure and collect the right

amount of tax.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated average

time is 15 minutes. If you have comments concerning the

accuracy of this time estimate or suggestions for making this

form simpler, we would be happy to hear from you. You can

write to the Tax Forms Committee, Western Area Distribution

Center, Rancho Cordova, CA 95743-0001. DO NOT send the

form to this address. Instead, see Where To File below.

Printed on recycled paper

A paid preparer must sign Form 8453-NR in the space for Paid

Preparer’s Use Only. But if the paid preparer is also the

MMRO, do not complete the paid preparer’s section. Instead,

check the box labeled “Check if also paid preparer.”

The IRS requires the MMRO’s signature.

form, report, or other statement generated by the financial

institution with the routing transit number (RTN), taxpayer’s

name, and depositor account number (DAN) printed on it.

All filers must check one of the boxes for line 11.