Form 8802

(Rev. October 2009)

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. If a

P.O. box, see instructions.

Appointee Information (see instructions):

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

Mail Form 6166 to the following address:

Applicant is (check appropriate box(es)):

Individual. Check all applicable boxes.

Partnership. Check all applicable boxes.

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

Estate

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 10003D Form 8802 (Rev. 10-2009)

a

b

c

d

e

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

4

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 or countries 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 all applicable boxes.

Section 501(c)

Other (specify) 

Section 457(b)

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

If a separate certification is needed for spouse, check here 

1 Applicant’s name and taxpayer identification number as it should appear on the certification if different from above

b

Check if:

Check if:

CAF No. 

Phone No. ( ) Fax No. ( )

LLC

Rev. Rul. 81-100 Trust

Section 584

IRA (for Individual)

U.S. citizen Sole proprietor

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

U.S. Foreign

Complex

Section 501(c)(3)

Additional request (see instructions)

IRA (for Financial Institution)

i Disregarded entity. Check if:

Indian tribe

Governmental entity

j Nominee applicant (must specify the type of entity/individual for whom the nominee is acting) 

Foreign claim form attached

LLC LP LLP Other (specify) 

Appointee Name 

Electronic payment confirmation no. 

Current nonimmigrant status and date of change (see instructions) 

See separate instructions.
7

8

9

Calendar year(s) for which certification is requested.

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

Purpose of certification. Must check applicable box (see instructions).

Form 8802 (Rev. 10-2009)

Income tax VAT (specify NAICS codes) 

Other (must specify) 

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)

Keep a

copy for

your

records. Signature

Applicant’s daytime phone no.:

Was the applicant’s parent, parent organization or owner required to file a U.S. tax form? (Complete this line only if you checked

“No” on line 5.)

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/owner’s name and address 

Name and title (print or type)

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

Name (print or type)

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 

QSub U.S. DRE

5500

Section 761(a) election

FASIT Foreign partnership

Foreign DRE

3520-A

10 Enter penalties of perjury statements and any additional required information here (see instructions).

Date

Applicant name:

Page 2

Note. If certification is for the current calendar year or a year for which a tax return is not yet required to be filed, a penalties

of perjury statement from Table 2 of the instructions must be entered on line 10 or attached to Form 8802 (see instructions).
11 Enter the number of certifications needed in the column to the right of each country for which certification is requested.

Form 8802 (Rev. 10-2009) Page 3

Country # Country

Armenia

Australia

Austria

Azerbaijan

Applicant Name

Appointee Name (If Applicable)

User Fee Voucher for U.S. Residency Certification Application

Applicant TIN For IRS use only:

Pmt Amt $

Date Pmt Verified:

Column A

CC

Column B

CC # Country

Column C

CC # Country

Column D

CC #

AM

AS

AU

AJ

Barbados

Belarus

Belgium

BB

BO

BE

Canada CA

China

Cyprus

Czech Republic

Denmark DA

EZ

CY

CH

Column A - Total Column B - Total Column C - Total Column D - Total

Egypt

Estonia

Finland

France

EG

EN

FI

FR

Georgia

Germany

GG

GM

Greece GR

Hungary HU

Iceland IC

India IN

Indonesia ID

Ireland

Israel

Italy

Jamaica

Japan

Kazakhstan

Korea, South

Kyrgyzstan

Latvia LG

KG

KS

KZ

JA

JM

IT

IS

EI

Lithuania

Luxembourg

LH

LU

Mexico MX

Moldova MD

Morocco MO

New Zealand NZ

Netherlands NL

Norway

Pakistan

Philippines RP

PK

NO

Poland

Portugal

Romania

Russia RS

RO

PO

PL

Slovak Republic LO

Slovenia

South Africa

SI

SF

Spain SP

Sri Lanka CE

Switzerland SZ

Tajikistan TI

Thailand TH

Trinidad and Tobago TD

Tunisia

Turkey

Turkmenistan

Ukraine

United Kingdom UK

UP

TX

TU

TS

Venezuela VE

12a Enter the total number of certifications requested (add

columns A, B, C, and D of line 11) 

If the total number of certifications is 20 or less, go to line 13

If the total on line a is greater than 20, enter $5 for each

additional 20 certifications 

13 Amount owed. Add lines 12b and 12c 

$35

/ /

b

c

12a

13

12b

12c

Calendar year(s) for which certification is requested (must be the same year(s) indicated on line 7)

Sweden SW

Uzbekistan UZ

Bangladesh BG

Bermuda BD

Number of

Forms 6166 User Fee

1 - 20 $ 35.00

21 - 40 $ 40.00

41 - 60 $ 45.00

61 - 80 $ 50.00

81 - 100 $ 55.00

Number of

Forms 6166 User Fee

101 - 120 $ 60.00

121 - 140 $ 65.00

141 - 160 $ 70.00

161 - 180 $ 75.00

181 - 200 $ 80.00

Note. If you are requesting certifications for more than one calendar year per country, enter the total number of certifications for all

years for each country (see instructions).

Bulgaria BU

Deposit Date:

/ /