| 0010 |
Initial Info Statement Box |
|
| 0020 |
Annual Info Statement Box |
|
| 0030 |
Date of Birth |
|
| 0040 |
Tax Year |
|
| 0050 |
Expatriate Identification Number |
1 |
| 0060 |
Mailing Street Addr Name Line 2 after Expatriation |
2 |
| 0070 |
Mailing Street Address after Expatriation |
2 |
| 0080 |
Mailing City after Expatriation |
2 |
| 0090 |
Mailing State or Province after Expatriation |
2 |
| 0100 |
Mailing Foreign Country after Expatriation |
2 |
| 0110 |
Mailing Postal Code after Expatriation |
2 |
| 0120 |
Telephone Number after Expatriation |
2 |
| 0130 |
Foreign Residence Street Name Line 2 |
3 |
| 0140 |
Foreign Residence Street Address |
3 |
| 0150 |
Foreign Residence City |
3 |
| 0160 |
Foreign Residence State or Province |
3 |
| 0170 |
Foreign Residence Country |
3 |
| 0180 |
Foreign Residence Postal Code |
3 |
| 0190 |
Foreign Tax Residence Country |
4 |
| 0200 |
Citizen Box |
5a |
| 0210 |
Date Dept Of State Notification |
5a |
| 0220 |
Long-Term Resident Box |
5b |
| 0230 |
Date Dept Of Homeland Security Notification |
5b |
| 0240 |
Dual Residency Long-Term Resident Box |
5c |
| 0250 |
Date Of Treaty Country Residence |
5c |
| 0260 |
US Income Tax 1st Year before Expat |
6 |
| 0270 |
US Income Tax 2nd Year before Expat |
6 |
| 0280 |
US Income Tax 3rd Year before Expat |
6 |
| 0290 |
US Income Tax 4th Year before Expat |
6 |
| 0300 |
US Income Tax 5th Year before Expat |
6 |
| 0310 |
Net Worth on Expat Date |
7 |
| 0320 |
Dual Citizen at Birth/Continuing Yes Box |
8 |
| 0330 |
Dual Citizen at Birth/Continuing No Box |
8 |
| 0340 |
Substantial US Contacts Yes Box |
9 |
| 0350 |
Substantial US Contacts No Box |
9 |
| 0360 |
Section 877(c)(3) Minor Yes Box |
10 |
| 0370 |
Section 877(c)(3) Minor No Box |
10 |
| 0380 |
5-Year Tax Compliance Yes Box |
11 |
| 0390 |
5-Year Tax Compliance No Box |
11 |
| 0410 |
Foreign Country Citizenship (1) |
12a |
| 0420 |
How Citizenship Acquired Literal (1) |
12b |
| 0430 |
Date of Country Citizenship (1) |
12c |
| 0440 |
Foreign Country Citizenship (2) |
12a |
| 0450 |
How Citizenship Acquired Literal (2) |
12b |
| 0460 |
Date of Country Citizenship (2) |
12c |
| 0470 |
Foreign Country Citizenship (3) |
12a |
| 0480 |
How Citizenship Acquired Literal (3) |
12b |
| 0490 |
Date of Country Citizenship (3) |
12c |
| 0500 |
Number of Days in US |
13 |
| 0510 |
US Presence 30 to 60 Days Yes Box |
14 |
| 0520 |
US Presence 30 to 60 Days No Box |
14 |
| 0530 |
Unrelated Employer Services Yes Box |
14a |
| 0540 |
Unrelated Employer Services No Box |
14a |
| 0550 |
Citizen/Resident Country of Birth Yes Box |
14b |
| 0560 |
Citizen/Resident Country of Birth No Box |
14b |
| 0580 |
Assets/Liabilities Changes Prior 5 Years Statement |
|
| 0590 |
Assets/Liabilities Changes Expect 10 Years Stmt |
|
| 0600 |
FMV Cash |
a1 |
| 0610 |
FMV US Stock and Securities |
a2 |
| 0620 |
FMV Foreign Stock and Securities |
a3 |
| 0630 |
FMV Nonmarketable US Stock and Securities |
a4 |
| 0640 |
FMV Nonmarketable Foreign Stock and Securities |
a5 |
| 0650 |
FMV Former CFC Stock |
a5a |
| 0660 |
US Adj Basis Former CFC Stock |
b5a |
| 0670 |
Gain/Loss Former CFC Stock |
c5a |
| 0680 |
FMV Res Former CFC Stock |
d5a |
| 0690 |
Company Name |
5b |
| 0700 |
Company EIN |
5b |
| 0710 |
Company Street Address |
5b |
| 0720 |
Company City |
5b |
| 0730 |
Company State Code |
5b |
| 0740 |
Company Zip Code |
5b |
| 0750 |
Company Foreign State or Province |
5b |
| 0760 |
Company Foreign Country Name |
5b |
| 0770 |
Company Foreign Postal Code |
5b |
| 0780 |
FMV Internal US Pensions |
a6 |
| 0790 |
FMV External US Pensions |
a7 |
| 0800 |
Total FMV Partnership Interests |
a8 |
| 0810 |
Individual Partnership Name |
8 |
| 0820 |
Individual Partnership EIN |
8 |
| 0830 |
Ind FMV Partnership Interest |
8 |
| 0840 |
Ind US Adj Basis Partnership Interest |
8 |
| 0850 |
Ind Gain/Loss Partnership Interest |
8 |
| 0860 |
Ind FMV Res Partnership Interest |
8 |
| 0870 |
Total FMV Trusts Assets |
a9 |
| 0880 |
Individual Trust Name |
9 |
| 0890 |
Individual Trust EIN |
9 |
| 0900 |
Ind FMV Trust Assets |
9 |
| 0910 |
Ind US Adj Basis Trust Assets |
9 |
| 0920 |
Ind Gain/Loss Trust Assets |
9 |
| 0930 |
Ind FMV Res Trust Assets |
9 |
| 0940 |
Total FMV Nongrantor Trusts Interests |
a10 |
| 0950 |
Individual Nongrantor Trust Name |
10 |
| 0960 |
Individual Nongrantor Trust EIN |
10 |
| 0970 |
Ind FMV Nongrantor Trust Assets |
10 |
| 0980 |
Ind US Adj Basis Nongrantor Trust Assets |
10 |
| 0990 |
Ind Gain/Loss Nongrantor Trust Assets |
10 |
| 1000 |
Ind FMV Res Nongrantor Trust Assets |
10 |
| 1010 |
FMV Internal US Intangibles |
a11 |
| 1020 |
FMV External US Intangibles |
a12 |
| 1030 |
FMV Loans to US Persons |
a13 |
| 1040 |
FMV Loans to Foreign Persons |
a14 |
| 1050 |
FMV US Real Property |
a15 |
| 1060 |
FMV Foreign Real Property |
a16 |
| 1070 |
FMV US Business Property |
a17 |
| 1080 |
FMV Foreign Business Property |
a18 |
| 1090 |
Total FMV Other Assets |
a19 |
| 1100 |
Individual Other Assets Description |
19 |
| 1110 |
Ind FMV Other Assets |
19 |
| 1120 |
Ind US Adj Basis Other Assets |
19 |
| 1130 |
Ind Gain/Loss Other Assets |
19 |
| 1140 |
Ind FMV Res Other Assets |
19 |
| 1150 |
FMV Total Assets |
a20 |
| 1160 |
FMV Installment Obligations Amount |
a21 |
| 1170 |
FMV Mortgage/Etc Amount |
a22 |
| 1180 |
FMV Total Other Liabilities Amount |
a23 |
| 1190 |
FMV Ind Other Liabilities Description |
a23 |
| 1200 |
FMV Ind Other Liabilities Amount |
a23 |
| 1210 |
FMV Total Liabilities Amount |
a24 |
| 1220 |
FMV Net Worth Amount |
a25 |
| 1230 |
US Adj Basis Cash |
b1 |
| 1240 |
US Adj Basis US Stock and Securities |
b2 |
| 1250 |
US Adj Basis Foreign Stock and Securities |
b3 |
| 1260 |
US Adj Basis Nonmarketable US Stock and Securities |
b4 |
| 1270 |
US Adj Basis Nonmarketable Foreign Stock & Secur. |
b5 |
| 1280 |
US Adj Basis Internal US Pensions |
b6 |
| 1290 |
US Adj Basis External US Pensions |
b7 |
| 1300 |
Total US Adj Basis Partnership Interests |
b8 |
| 1310 |
Total US Adj Basis Trusts Assets |
b9 |
| 1320 |
US Adj Basis Internal US Intangibles |
b11 |
| 1330 |
US Adj Basis External US Intangibles |
b12 |
| 1340 |
US Adj Basis Loans to US Persons |
b13 |
| 1350 |
US Adj Basis Loans to Foreign Persons |
b14 |
| 1360 |
US Adj Basis US Real Property |
b15 |
| 1370 |
US Adj Basis Foreign Real Property |
b16 |
| 1380 |
US Adj Basis US Business Property |
b17 |
| 1390 |
US Adj Basis Foreign Business Property |
b18 |
| 1400 |
Total US Adj Basis Other Assets |
b19 |
| 1410 |
US Adj Basis Total Assets |
b20 |
| 1420 |
Gain/Loss Cash |
c1 |
| 1430 |
Gain/Loss US Stock and Securities |
c2 |
| 1440 |
Gain/Loss Foreign Stock and Securities |
c3 |
| 1450 |
Gain/Loss Nonmarketable US Stock and Securities |
c4 |
| 1460 |
Gain/Loss Nonmarketable Foreign Stock & Securities |
c5 |
| 1470 |
Gain/Loss Internal US Pensions |
c6 |
| 1480 |
Gain/Loss External US Pensions |
c7 |
| 1490 |
Total Gain/Loss Partnership Interests |
c8 |
| 1500 |
Total Gain/Loss Trusts Assets |
c9 |
| 1510 |
Gain/Loss Internal US Intangibles |
c11 |
| 1520 |
Gain/Loss External US Intangibles |
c12 |
| 1530 |
Gain/Loss Loans to US Persons |
c13 |
| 1540 |
Gain/Loss Loans to Foreign Persons |
c14 |
| 1550 |
Gain/Loss US Real Property |
c15 |
| 1560 |
Gain/Loss Foreign Real Property |
c16 |
| 1570 |
Gain/Loss US Business Property |
c17 |
| 1580 |
Gain/Loss Foreign Business Property |
c18 |
| 1590 |
Total Gain/Loss Other Assets |
c19 |
| 1600 |
Gain/Loss Total Assets |
c20 |
| 1610 |
FMV Res Cash |
d1 |
| 1620 |
FMV Res US Stock and Securities |
d2 |
| 1630 |
FMV Res Foreign Stock and Securities |
d3 |
| 1640 |
FMV Res Nonmarketable US Stock and Securities |
d4 |
| 1650 |
FMV Res Nonmarketable Foreign Stock and Securities |
d5 |
| 1660 |
FMV Res Internal US Pensions |
d6 |
| 1670 |
FMV Res External US Pensions |
d7 |
| 1680 |
Total FMV Res Partnership Interests |
d8 |
| 1690 |
Total FMV Res Trusts Assets |
d9 |
| 1700 |
FMV Res Internal US Intangibles |
d11 |
| 1710 |
FMV Res External US Intangibles |
d12 |
| 1720 |
FMV Res Loans to US Persons |
d13 |
| 1730 |
FMV Res Loans to Foreign Persons |
d14 |
| 1740 |
FMV Res US Real Property |
d15 |
| 1750 |
FMV Res Foreign Real Property |
d16 |
| 1760 |
FMV Res US Business Property |
d17 |
| 1770 |
FMV Res Foreign Business Property |
d18 |
| 1780 |
Total FMV Res Other Assets |
d19 |
| 1790 |
FMV Res Total Assets |
d20 |
| 1810 |
US Not-Eff-Con Interest Income |
1a |
| 1820 |
US Not-Eff-Con Dividend Income |
1b |
| 1830 |
US Not-Eff-Con Royalty Income |
1c |
| 1840 |
US Not-Eff-Con Pension Income |
1d |
| 1850 |
US Not-Eff-Con Total Other Income |
1e |
| 1860 |
US Not-Eff-Con Ind Other Income Description |
1e |
| 1870 |
US Not-Eff-Con Ind Other Income Amount |
1e |
| 1880 |
US Not-Eff-Con Total Income |
1f |
| 1890 |
US Eff-Con Gross Income |
2 |
| 1900 |
US Personal Service Income |
3 |
| 1910 |
US Property Sales Gains |
4a |
| 1920 |
US Stock Sales Gains |
4b |
| 1930 |
US Debt Obligation Sales Gains |
4c |
| 1940 |
US Total Sales Gains |
4d |
| 1950 |
Pre-Expat Income/Gains from Certain Foreign Corps |
5 |
| 1960 |
Certain Property Exchange Gains |
6 |
| 1970 |
Certain Foreign Corps Income |
7 |
| 1980 |
Total Lines 1 To 7 |
8 |
| 1990 |
Other Source Gross Income |
9 |
| 2000 |
Total Gross Income |
10 |
