8854 Expatriation Information Statement Form

© See separate instructions. © Please print or type.

Department of the Treasury

Internal Revenue Service

Name

General Information. For all filers.

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

Identifying number. (See instructions.)

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

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

Country of tax residence (if different from line C)

Date of notification of expatriating act, termination of residency, or claim of treaty benefits. (See instructions.)

Citizen. Date notification given to Department of State

Long-term resident. Date notification given to Department of Homeland Security

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 (2008)

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

1st Year

Before Expatriation

$

2nd Year

Before Expatriation

$

3rd Year

Before Expatriation

$

4th Year

Before Expatriation

$

5th Year

Before Expatriation

$

6

5

2

3

4

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 penalties 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.

Expatriation date. Check the box that applies. (See instructions.)

Before June 17, 2008. Complete Part A.

After June 16, 2008. Complete Part B.

OMB No. 1545-0074

Attachment

Sequence No. 112

2008

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 9

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

during the tax year?

8

9

Yes No

Were you performing services for an unrelated employer?

If you checked “Yes” to line 9a, 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 was born?

a

b

Yes No

Yes No

7

Do not complete Section II if:

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

Name of country

How you became a U.S. citizen

a

b

c

● You checked “Yes” to line 5 and “Yes” to line 6.

● You checked “Yes” to line 3, “No” to line 4, and “Yes” to line 6; or

● Your average annual net income tax liability for the 5 tax years immediately before expatriation (see line 1) was not more

than the limit listed under Taxation Under Section 877 on page 1 of the instructions, your net worth on line 2 was under 

$2 million, and you checked “Yes” to line 6;

Date you became a citizen of each country listed in 7a

Part A For Persons Who Expatriated Before June 17, 2008

Initial Information Statement.

Annual Information Statement. Do not complete Section I.

Section II Annual Information Statement Under Section 6039G

Section I Initial Information Statement

Check the box that applies.

A

B

C

D

E

F
Form 8854 (2008) Page 2

Provide the name, address, and EIN, if any, of 

any such company

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.

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.

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 (2008)

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

Schedule A Balance Sheet
Form 8854 (2008) Page 3

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 ordinarily would not be recognized. (See instructions.)

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

10 Total. Add lines 8 and 9 10

● If this is an initial information statement, provide income information for that part of the tax 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.

Form 8854 (2008)

Schedule B Income Statement
Form 8854 (2008) Page 4

Part B For Persons Who Expatriated After June 16, 2008

Section I Expatriation Information

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

1st Year

Before Expatriation

$

2nd Year

Before Expatriation

$

3rd Year

Before Expatriation

$

4th Year

Before Expatriation

$

5th Year

Before Expatriation

$

6

5

2

3

4

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, and taxed as a resident of, that other country?

If you answered “Yes” to question 3, have you been a resident of the U.S. for not more than 10 of the

last 15 tax years?

Were you under age 181⁄2 on the date you expatriated and have you been a U.S. resident for more than 

10 years?

Yes No

Yes

No

No

Yes No

Do you certify under penalties of perjury that you have complied with all of your tax obligations for the 5 

preceding tax years? (See instructions.)

$

Form 8854 (2008)

Section II

Complete column (g) only if you are deferring tax on gain from any property listed in column (a).

8

(a)

Description of property

9 Total. Add the amounts in column (d) and column (e)

10 Total Tax Deferred. Add the amounts in column (g). Enter

here and on line 15

*You must designate any property for which you are electing to figure basis without regard to section 877A(h)(2). Identify as “(h)(2).” This election is irrevocable.

(b)

Fair market value

on day before date

of expatriation

(c)

Cost or other

basis*

(d)

Gain or (loss).

Subtract (c)

from (b)

(g)

Amount of tax

deferred (attach

computations)

Recognition of Gain or Loss on the Deemed Sale of Mark-To-Market Property

7a

Yes No

Do you have any eligible deferred compensation items? Checking the “Yes” box is an irrevocable waiver 

of any right to claim any reduction in withholding for such eligible deferred compensation item under any 

treaty with the United States

b

Yes No

Do you have any ineligible deferred compensation items? If “Yes,” you must include in income the

present value of your account on the day before your expatriation date

c

Yes No

Do you have any specified tax deferred accounts? If “Yes,” you must include in income the entire account 

balance on the day before your expatriation date

d

Yes No

Do you have an interest in a nongrantor trust? Checking the “Yes” box is a waiver of any right to claim 

any reduction in withholding on any distribution from such trust under any treaty with the United States

unless you make the election below

Check this box to elect under section 877A(f)(4)(B) to be treated as having received the value of your entire interest in the 

trust (as determined for purposes of section 877A) as of the day before your expatriation date. Attach a copy of your

valuation letter ruling issued by the IRS. (See instructions.)

(e)

Gain after

allocation of the

exclusion amount

(see instructions)

(f)

Form or Schedule

on which gain

asset is reported
Form 8854 (2008) Page 5

Form 8854 (2008)

Section III Deferral of Tax

11 Are you electing to defer tax under section 877A(b)?

Checking the “Yes” box is an irrevocable waiver of any right under any treaty of the 

United States that would prevent assessment or collection of any tax imposed because of section 877A

If you checked the “Yes” box, continue to line 12. Otherwise, do not complete lines 12 through 15.

Election To Defer Tax. You can defer tax only if you have provided adequate security. Adequate security is described on

page 8 of the instructions.

Enter the total tax you would have reported on Form 1040, line 61, for the part of the year

including the day before the expatriation date absent the deferral election

12

12

13 Enter the total tax for the same part of the tax year determined without regard to the amounts

attributable to section 877A(a). Attach computation 13

14 Subtract line 13 from line 12. This is the amount of tax eligible for deferral 14

● If you are filing Form 1040, enter this amount in brackets to the left of the entry space for line

61. Identify as “EXP.” Subtract that amount from the total of lines 56 through 60, and replace the 

previous entry on line 61 with this difference.

● If you are filing Form 1040NR, enter this amount in brackets to the left of the entry space for

line 57. Identify as “EXP.” Subtract that amount from the total of lines 51 through 56, and replace 

the previous entry on line 57 with this difference.

Yes No

15 Enter the total tax deferred from line 10, column (g) 15

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