Form 1040NR (2003), Page 5. Summary: This is an example of Form 1040NR (2003), page 5, with items included as described in the text. Additionally, these
line items are
completed:
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“A. What country issued your passport?” field contains United Kingdom
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“B. Were you ever a U.S. citizen? No” checkbox checked
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“C. Give the purpose of your visit to the United States” field contains Temporary assignment
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“D. Type of entry visa” field contains H-1
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“and current nonimmigrant status and date of change (see page 24)” field contains Permanent 3-18-03
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“G. Dates you entered and left the United States during the year. Residents of Canada or Mexico entering and leaving the United
States at
frequent intervals, give name of country only.” field contains
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| Entered--March 18, 2003
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| Departed--May 25, 2003
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| Entered--September 10, 2003
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“H. Give number of days (including vacation and nonworkdays) you were present in the United States during:”
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“2001” field contains 0
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“2002” field contains 0
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“and 2003” field contains 182
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“J. Did you file a U.S. income tax return for any year before 2003? No” checkbox checked
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“M. If you are claiming the benefits of a U.S. income tax treaty with a foreign country, give the following information. See
page 24 for
additional information.”
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“Country” field contains United Kingdom
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“Type and amount of income not effectively connected that is exempt from or subject to a reduced rate of tax. Also, identify
the applicable tax
treaty article: For 2003” field contains Additional income of $240 taxed at 15% under Article 10
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“Were you subject to tax in that country on any of the income you claim is entitled to the treaty benefits? Yes” checkbox
checked
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“Did you have a permanent establishment or fixed base (as defined by the tax treaty) in the United States at any time during
2003? No”
checkbox checked
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“P. Is this an expatriation return (see page 24)? No” checkbox checked
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“Q. During 2003, did you apply for, or take other affirmative steps to apply for, lawful permanent resident status in the United
States or have
an application pending to adjust your status to that of a lawful permanent resident of the United States? Yes” checkbox checked
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“If Yes, explain” field contains Permanent resident status
granted
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