Cat. No. 24126N

OMB No. 1545-1567

Form 8854 Expatriation Initial Information Statement

 See separate instructions.  Please print or type. Department of the Treasury

Internal Revenue Service

Name Identifying number

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

3

Was your average annual net U.S. income tax liability (after credits) for the 5-tax-year period that ended before

the date of expatriation more than $124,000 (for expatriation in 2004) or the applicable threshold amount (see

instructions for this line) for expatriation before 2004?

For Paperwork Reduction Act Notice, see separate instructions. Form 8854 (Rev. 2-2004)

Part I

7

8

Mailing address where you may be reached after expatriation 4 Address of tax residence after expatriation (if different from 3)

5 Address of tax residence before expatriation

6 List all foreign countries (not the United States) of which you are a citizen.

a Name of country b How you became a citizen c Date you became a citizen

Number of days you were present

in the United States during the

Tax year of expatriation

Tax year before expatriation

Tax year that is 2 years before expatriation

If “Yes,” enter your tax liability for each of those years (rounded to the nearest $50,000).

5th Year

Before Expatriation

$ $ $ $ $

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

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

a

b

c

a

b

c

9 Was your net worth on the date you expatriated equal to or more than $622,000 (for expatriation in 2004)

or the applicable threshold amount (see instructions for this line) for expatriation before 2004? If “Yes,”

complete Part II on the back

Yes No

Telephone number

Attachment

Sequence No. 112

1 Date of expatriation

b If you are a former U.S. long-term resident (LTR), check this box 

Yes No

If you checked the “Yes” box on line 8 or line 9, see instructions and complete lines 10 a, b, and c.

Are you eligible to submit a ruling request that your expatriation did not have, as one of its principal

purposes, the avoidance of U.S. taxes?

Did you submit or do you intend to submit such a ruling request?

If you submitted a ruling request, did you receive a ruling that either:

a

b

c

10

Yes No

Yes No

Yes No

2a If you are a former U.S. citizen, check this box 

(1) Your ruling request was complete and submitted in good faith?

(2) Your expatriation did not have as one of its principal purposes the avoidance of U.S. taxes under

Internal Revenue Code section 877(a)(1)?

Yes No

(Rev. February 2004)



4th Year

Before Expatriation

3rd Year

Before Expatriation

2nd Year

Before Expatriation

1st Year

Before Expatriation
Form 8854 (Rev. 2-2004) Page 2

Balance Sheet

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 19

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) immediately

prior to expatriation

(b) U.S. adjusted

basis immediately

prior to expatriation

(c) Gain or (Loss).

Subtract column (b)

from column (a)

Mortgages, etc.

Part II

Pensions from services performed outside

the United States

Beneficial interests in nongrantor trusts (see

instructions)

14 Loans to foreign persons

15

16

Amount

● Complete Part II only if you checked the “Yes” box on line 9 in Part I.

● List the amounts of your assets and liabilities in U.S. dollars immediately prior to expatriation.

● 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 (Rev. 2-2004)