Cat. No. 24126N

OMB No. 1545-1567

Form 8854 Expatriation 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. Complete Part II if, on the date of expatriation, you

had gross assets with a collective fair market value of more than $500,000. 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: $110,000 for expatriations in 1999; $109,000 for expatriations

in 1998; or $106,000 for expatriations in 1997?

For Paperwork Reduction Act Notice, see separate instructions. Form 8854 (1-99)

Part I

7

8

11

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

$ $ $ $ $

At the time of expatriation, did you have gross assets with a collective fair market value of more than $500,000?

If “Yes,” complete Part II on the back.

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: $552,000 for expatriations in

1999; $543,000 for expatriations in 1998; or $528,000 for expatriations in 1997?

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

Yes No

If you answered “Yes” to question 8 or 9, see instructions and answer questions 10 a, b, and c. Otherwise,

go to question 11.

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

(January 1999)

$

4th Year

Before Expatriation

3rd Year

Before Expatriation

2nd Year

Before Expatriation

1st Year

Before Expatriation
Form 8854 (1-99) 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

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 this Part only if you answered “Yes” to question 11 in Part I.

● List the amounts of your assets and liabilities 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.

● See the separate instructions for further information.

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)