Form 8802

(December 2003)

Department of the Treasury

Internal Revenue Service

Application for United States

Residency Certification OMB No. 1545-1817

2

3a

Applicant’s name

If a joint return was filed, spouse’s name (see instructions)

Applicant’s U.S. taxpayer identification number

Applicant’s address during the calendar year for which certification is requested, including country and ZIP or postal code (see

instructions)

Appointee’s name and address (if any)

U.S. permanent resident alien (green card holder)

Mail the certification to (check the appropriate box):

Applicant is (check appropriate box(es)):

Individual. Check all applicable boxes.

Partnership. Check all applicable boxes.

Corporation. If incorporated in the United States, go to line 5. Otherwise, continue.

Estate

For Privacy Act and Paperwork Reduction Act Notice, see page 5 of the instructions. Cat. No. 10003D Form 8802 (12-2003)

a

b

c

d

e

Dual-status U.S. resident (see instructions). From  to 

4

Address on line 2

If a joint return was filed, spouse’s U.S. taxpayer

identification number

Section 269B Section 943(e)(1) Section 953(d) Section 1504(d)

Trust. Check if: Grantor (U.S.) Simple

Grantor (foreign)

Country of incorporation 

If a dual-resident corporation, specify other country of residence  

If included on a consolidated return, attach page 1 of Form 1120 and Form 851.

f S corporation

g Employee benefit plan/trust. Plan number, if applicable 

Section 401(a) Section 403(b)

h Exempt organization. If organized in the United States, check applicable box.

Section 501(c)(3) Other (specify) 

Section 457

Appointee’s (see instructions):

Address shown on the attached Form 2848 or Form 8821

Address on line 3b

Other U.S. resident alien. Type of entry visa 

Current nonimmigrant status  and date of change (see instructions) 

If a separate certification is needed for spouse, check here 

1 Name and taxpayer identification number as it should appear on the certification if different from above

Other (specify) 

b c

Check if:

Check if:

CAF/Appointee No. 

Phone No. 

Fax No. 

( )

( )

Was the applicant required to file a U.S. tax form for the tax period(s) on which certification will be based?

990 990-T 1040 1041 1065 1120 5227

Check the appropriate box for the form filed and go to line 7.

1120S

5

Yes.

Other (specify) 

No. Attach explanation (see instructions). Check applicable box and go to line 6.

Minor child

Other 

LLC

 See separate instructions

Rev. Rul. 81-100 Trust

QSub U.S. DRE (LLC)

IRA

Section 584

5500

Section 761(a) election

FASIT Foreign partnership

U.S. citizen

Sole proprietor

Partial-year Form 2555 filer (see instructions). U.S. resident from  to 

U.S. Foreign

Complex

Governmental entity

Foreign DRE
7

8

9

10

Calendar year(s) for which certification is requested (see instructions)

Tax period(s) on which certification will be based (see instructions)

Enter the number of certifications needed in the column to the right of each country for which certification is requested (see

instructions)

Purpose of certification. Check applicable box.

Form 8802 (12-2003)

Form 8802 (12-2003) Page 2

Income tax VAT (specify NAICS codes) 

Other (specify)  

Country # Country Country Country Country # ## #

Armenia

Australia

Austria

Azerbaijan

Barbados

Belarus

Belgium

Canada

China

Cyprus

Czech Rep.

Denmark

Egypt

Estonia

Finland

France

Georgia

Germany

Greece

Hungary

Iceland

India

Indonesia

Ireland

Israel

Italy

Jamaica

Japan

Kazakhstan

Rep. of Korea

Latvia

Lithuania

Luxembourg

Mexico

Moldova

Morocco

Netherlands

New Zealand

Norway

Pakistan

Philippines

Poland

Portugal

Romania

Russia

Slovak Rep.

Slovenia

South Africa

Spain (see

page 2 of the

instructions)

Sweden

Switzerland

Tajikistan

Thailand

Trinidad & Tobago

Tunisia

Turkey

Turkmenistan

Ukraine

United Kingdom (see

page 2 of the instructions)

Uzbekistan

Venezuela

Other(s) (specify

below)

11 This space can be used to enter additional required information

Under penalties of perjury, I declare that I have examined this application and accompanying attachments, and to the best of my knowledge and

belief, they are true, correct, and complete. If I have designated a third party to receive the residency certification(s), I declare that the certification(s)

will be used only for obtaining information or assistance from that person relating to matters designated on line 9.

Sign

here

Applicant’s signature (or individual authorized to sign for the applicant) Date

Keep a

copy for

your

records.  Spouse’s signature. If a joint application, both must sign. Date

Capacity in which acting Daytime phone number

Was the applicant’s parent or parent organization required to file a U.S. tax form?

990 990-T 1040 1041 1065 1120 5500

and U.S. taxpayer identification number 

Check the appropriate box for the form filed by the parent.

Attach explanation (see instructions).

1120S

6

Yes.

No.

Other (specify) 

Parent’s name and address 

( )

Kyrgyzstan