8854 Initial and Annual Expatriation Information Statement Form

© See separate instructions. © Please print or type.

Department of the Treasury

Internal Revenue Service

Name

Part I General Information. All filers must complete Part I. See instructions.

Date of birth (mo., day, yr.) Tax Year

Identifying number (see instructions) ©

a

1

2

3

4

5

b

c

Mailing address and telephone number where you can be reached after expatriation

Address of principal foreign residence (if different from line 2)

Country of tax residence (if different from line 3)

Date of notification of expatriating act, termination of residency, or claim of treaty benefits. Check the box that applies

and enter the appropriate date.

Citizen. Date notification given to Department of State (see instructions).

Long-term resident. Date notification given to Homeland Security (see instructions).

Long-term resident with dual residency in a treaty country. Date commencing to be treated, for tax purposes, as a

resident of the treaty country .

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 24126N Form 8854 (2007)

6 Enter your U.S. income tax liability (after foreign tax credits) for the 5 tax years ending before the date of expatriation.

Part II Initial Expatriation or Termination Information Statement

1st Year

Before Expatriation

$

2nd Year

Before Expatriation

$

3rd Year

Before Expatriation

$

4th Year

Before Expatriation

$

5th Year

Before Expatriation

$

11

10

7

8

9

Enter your net worth on the date of your expatriation for tax purposes

Yes

Did you become at birth a U.S. citizen and a citizen of another country, and do you continue to be 

a citizen of that other country?

Do you have substantial contacts with the United States? (See instructions.)

Are you a minor described in section 877(c)(3)? (See instructions.)

Yes No

Yes

No

No

Yes No

Do you certify under penalty of perjury that you have complied with all of your tax obligations for

the 5 preceding tax years? (See instructions.)

$

© Section references on this form are to the Internal Revenue Code.

Initial or Annual Information Statement. Check the box that applies.

Initial Information Statement. Complete Parts I, II, and III, and Schedules A and B.

Annual Information Statement. Complete Parts I and III and Schedules A and B. Skip Part II (see instructions).

OMB No. 1545-0074

Attachment

Sequence No. 112

2007
Number of days you were physically present in the United States during the current year. If you were 

present in the United States more than 60 days, skip line 14

Were you physically present in the United States for more than 30 days but not more than 60 days 

during the tax year?

13

14

Yes No

Were you performing services for an unrelated employer?

If you checked “Yes” to line 14a, are you a citizen or resident, fully liable for income tax, in the 

country in which you were born, your spouse was born, or either of your parents were born?

a

b

Yes No

Yes No

Form 8854 (2007) Page 2

Form 8854 (2007)

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best 

of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than filer) is based on all information of which 

preparer has any knowledge.

Your signature

Preparer’s signature

Date

Date

Sign

Here

12

Do not complete this part if:

Part III Annual Information Reporting under Section 6039G

List all countries (other than the United States) of which you are a citizen.

Name of country

How you became a citizen

a

b

c

●

●

● You checked “Yes” to line 10, and you checked “Yes” to line 11.

You checked “Yes” to line 8 and “No” to line 9, and you checked “Yes” to line 11, or

Your average annual net income tax liability for years 1-5 (line 6) was not more than the limit listed under Taxation Under

Section 877 on page 1 of the instructions and your net worth on line 7 was under $2,000,000, and you checked “Yes” to

line 11, or

Date you became a citizen
Provide the name, address, and EIN, if any, of 

any such company

Form 8854 (2007) Page 3

Assets

1

2

3

4

5

6

7

8

9

10

11

12

13

21

22

23

24

25

Cash, including bank deposits

Marketable stock and securities issued by

U.S. companies

Marketable stock and securities issued by

foreign companies

Nonmarketable stock and securities issued by 

U.S. companies

Nonmarketable stock and securities issued by 

foreign companies

Pensions from services performed in the

United States

Partnership interests (see instructions)

Assets held by trusts you own under

sections 671–679 (see instructions)

Intangibles used in the United States

Real property located in the United States

Business property located in the United

States

Other assets (see instructions)

Total assets. Add lines 1 through 5 and lines

6 through 19. Do not include amounts on line 

5a in this total

Installment obligations

Other liabilities (see instructions)

Total liabilities. Add lines 21 through 23

Net worth. Subtract line 24 from line 20,

column (a)

Liabilities

(a) Fair Market

Value (FMV)

(b) U.S. adjusted

basis

(c) Gain or (Loss).

Subtract column (b)

from column (a)

Mortgages, etc.

Schedule A

Pensions from services performed outside

the United States

Beneficial interests in nongrantor trusts

(see instructions)

14 Loans to foreign persons

15

16

Amount

● If this is an initial information statement, list in U.S. dollars the fair market value (column (a)) and the U.S. adjusted basis (column

(b)) of your assets and liabilities as of the date of your expatriation for tax purposes.

● If this is an annual information statement, list in U.S. dollars the fair market value (column (a)) and the U.S. adjusted basis

(column (b)) of your assets and liabilities as of the end of the tax year for which you are filing this form.

● If you are a former U.S. long-term resident (LTR), it may benefit you to complete column (d). Only former LTRs should do so.

For more details, see the separate instructions.

17

18

19

20

Intangibles used outside the United States

Loans to U.S. persons

Real property located outside the United

States

Business property located outside the

United States

(d) FMV on beginning

date of U.S. residency

(optional, for LTRs only)

Form 8854 (2007)

Separately state stock issued by foreign

companies that would be controlled foreign

corporations if you were still a U.S. citizen or 

permanent resident (see instructions)

b

a

Balance Sheet
1 U.S. source gross income not effectively connected with the conduct of a U.S. trade or business.

Gross income that is effectively connected with the conduct of a U.S. trade or business

3

5

Income from the performance of services in the United States 

4

5

Property (other than stock or debt obligations) located in the 

United States 

6

7

Stock issued by a U.S. domestic corporation

6

7

8

9

Debt obligations of U.S. persons or of the United States, a state or

political subdivision thereof, or the District of Columbia

8

1a

9

Gains on certain exchanges of property that would ordinarily not be recognized (see instructions)

Form 8854 (2007)Page 4

Interest

Dividends

Royalties

Pension distributions

Other

Total. Add lines a through e

Gains from the sale or exchange of:

Total. Add lines a through c

2

a

b

c

d

e

f

a

b

c

d

1f

1e

1d

1c

1b

3

4a

4b

4c

4d

2

Income or gain derived from certain foreign corporations to the extent of your share of earnings

and profits earned or accumulated before the date of expatriation (see instructions) 

Income received or accrued by certain foreign corporations (see instructions)

Add lines 1f, 2, 3, 4d, 5, 6, and 7 

Gross income from all other sources

Total. Add lines 8 and 9

10

Form 8854 (2007)

Schedule B Income Statement

10

● If this is an initial information statement, provide income information for that portion of the year that ends on the

date of your expatriation for tax purposes.

● If this is an annual information statement, provide income information for the tax year for which you are filing the

form.