Current Address:

American Samoa Guam Commonwealth of the Northern Mariana Islands 

Address in Possession (if different from current address):

General Information

1

2 Are you a U.S. citizen or resident alien (see instructions)?

4a If you checked box a on line 1 above, enter the date (month/day/year) you moved to the possession to establish bona fide residence

5a

Presence in the United States or Possession

6

8 Did you have a tax home outside the possession at any time during the tax year (see instructions)?

Where was your principal permanent home located during the tax year (see instructions)?

If you had more than one permanent home available to you at all times during the tax year, list the location of each:

Part I

Part II

Enter your average worldwide gross income for the three-year period prior to the tax year you became (or ceased

to be) a bona fide resident of the possession (see instructions)

3

9 Did you have a closer connection to the United States or a foreign country than to the possession at any time during the tax year?

Enter the number of days you were present in the United States during the tax year (see instructions)

Form 

I am notifying the IRS that I (check box a or b below and enter the tax year in the space provided):

b

c Of which U.S. possession did you become (or cease to be) a bona fide resident:

Commonwealth of Puerto Rico U.S. Virgin Islands

Yes 

b Enter the number of days you were present in the possession during the tax year (see instructions)

Did you have a significant connection to the United States during the tax year (see instructions)? Yes 

Part III Closer Connection to the United States, Foreign Country, or Possession

Yes 

If “Yes,” where?

Yes 

If “Yes,” where?

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 37706B

became

ceased to be a a bona fide resident of a U.S. possession in tax year 

If you checked box b on line 1 above, enter the date (month/day/year) you moved from the

possession to end bona fide residence

b

Note. Complete line 6 only if you are following the rules under Test for Tax Years Ending After January 31, 2006.

See page 1 of the instructions.

/

/

Where was your immediate family located during the tax year?

11

Where was your automobile(s) located during the tax year?

12

Where was your automobile(s) registered during the tax year?

13

Where were your personal belongings, furniture, etc., located during the tax year?

14

List social, cultural, religious, professional, and political organizations (including but not limited to country clubs and c

commerce) you participated in during the tax year and the location of each:

15

a

c

e

d

b

Location

Location

Location

Location

Location

16

17

Note. Skip line 5 if you are filing Form 8898 for the tax year that begins before October 23, 2004, and ends after October 22,

2004, and you are following the rules under Temporary Regulations section 1.937-1T. See page 1 of the instructions.

7 Did you have any earned income from U.S. sources during the tax year (see instructions)? Yes 

If “Yes” and you are following the rules under Test for Tax Years Ending After January 31, 2006, was the amount of the

income more than $3,000? Yes 

Note. Skip line 9 if you are following the rules under Test for Tax Years Ending Before October 23, 2004.

Note. Complete line 10 only if you are following the rules under Test for Tax Years Ending After January 31, 2006.

10 If you answered “Yes” to line 8 or line 9, are you using the year-of-the-move exception? Yes 

(See Exception for the Year of the Move on page 2 of the instructions.)
Did you claim a homestead exemption for the tax year (see instructions)?

If “Yes,” where?

22

Form 8

23 When completing official documents, forms, etc., what address did you list as your residence?

28 Where (for example, in the United States, possession, other country) were your investments located (see instructions)?

29 List any charitable organizations to which you made contributions during the tax year and their locations:

Did you have any income from possession sources for the tax year (see instructions)?

During the tax year, did you have an office in the possession from which you conducted a trade or business?

If “Yes,” what type(s)?

If “Yes,” provide the address of that office and a short description of your trade or business:

During the tax year, did you receive compensation for personal services?

During the tax year, did you manufacture an article in the possession for sale to customers?

If “Yes,” where did you perform these services?

27

30

31

32

24 Where (for example, in the United States, possession, other country) did you keep your personal, financial, and legal do

25 Where (for example, from the United States, possession, other country) did you derive the majority of your income for the tax yea

Did you have any income from U.S. sources for the tax year (see instructions)?

If “Yes,” what type(s)?

26

Part IV Source of Income

a

c

e

d

b

Location

Location

Location

Location

Location

Did you sell or exchange appreciated property during the tax year after becoming a resident of the possession?

If “Yes,” provide a short description of the property and the amount of the gain (see instructions).

If you conducted a trade or business in the possession during the tax year, did that business consist of:

b

33

34

a

c

Note. If you have any other information to substantiate your closer connection to the United States or the possession, or you wish t

more detail any of your responses, attach a statement to this form.

Sign

Here

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

belief, they are true, correct, and complete.

Your signature Date

Receiving rents or royalties for the use of intangible property?

Receiving dividends or interest in connection with a banking, financing, or similar business?

The sale or exchange (outside the possession) of personal property consisting of stock in trade or inventory?

Note. If you used more than one address, specify the type of documents, forms, etc., and the addresses used.

a

c

e

d

b

Address

Address

Address

Address

Address

Keep a copy for

your records.

Did you conduct business activities in a location other than your tax home?

If “Yes,” where?

20a Where was your driver’s license issued?

b If you hold a second driver’s license, where was it issued?

Yes 

Were you registered to vote during the tax year?

If “Yes,” where?

21 Yes 

19

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes