Generally, this number is your U.S. social security number. An incorrect or missing identifying number may result in failure to expatriate or terminate residency and/or a penalty of $10,000. If you were never issued a social security number, please attach a statement explaining the reason.

If you have a P.O. box, enter your box number instead of your street address only if your post office does not deliver mail to the street address.

Enter the information in the following order: street address, city, province or state, and country. Follow the country's practice for entering the postal code. Do not abbreviate the country name.

Enter the country of which you are considered a resident for tax purposes if different from the country in which your principal foreign residence is located.

If you have not yet notified the Secretary of State or Secretary of Homeland Security in connection with your expatriating act or termination of residency, you must file an amended Form 8854 stating the date on which such notification occurs.

Use the balance sheet in Schedule A to arrive at your net worth.

You have no substantial contacts with the United States if you (a) were never a resident of the United States (as defined in section 7701(b)), (b) never held a U.S. passport, and (c) were not present in the United States for more than 30 days during any of the 10 calendar years preceding your loss of U.S. citizenship.

Check the “Yes” box if:

Check the “Yes” box if you have complied with your tax obligations for the 5 tax years ending before the date on which you expatriated or terminated your residency, including but not limited to, your obligations to file income tax, employment tax, gift tax, and information returns, if applicable, and your obligation to pay all relevant tax liabilities, interest, and penalties. You will be subject to tax under section 877 if you have not complied with these obligations, regardless of whether your average annual income tax liability or net worth exceeds the applicable threshold amounts.

Section 877 does not apply to you if your net worth is less than $2 million as of the date of your tax expatriation, your average annual net income tax liability for the 5 tax years prior to the date of your tax expatriation was not more than the amount listed under Taxation under section 877 on page 2, and you certify that you have met your tax obligations for the 5 years prior to expatriation.

If you exceed these dollar thresholds and you certify that you have met your tax obligations, section 877 may still not apply to you if you meet one of the exceptions for dual citizens at birth with no substantial presence or for certain minors. See Exceptions to Section 877 on page 2.

You do not need to complete Part III of this form if:

List all foreign countries of which you are a citizen.

Indicate how you became a U.S. citizen. For example, if you acquired citizenship at birth, write “At Birth.” If you acquired citizenship through naturalization, write “Naturalized Citizen.”

Provide the date on which you became a citizen of each country listed on line 12a.

If you were physically present in the United States for more than 60 days during the tax year, you will be taxed as a U.S. citizen or resident and must file Form 1040 for the current tax year. If in a subsequent year within the 10-year period you are not physically present more than 30 days during the year, you will again be subject to section 877 and file Form 1040NR. If you were present more than 60 days during the year, skip line 14.

If you were physically present in the United States more than 30 days but not more than 60 days during the tax year, complete lines 14a and b. If you answer “No” to either question, you will be taxed as a U.S. citizen or resident and must file Form 1040 for the current tax year. If you answer “Yes” to both questions, you remain subject to section 877 for the tax year.

Form 8854 is not considered valid unless you sign it. If you have someone else prepare Form 8854, you are still responsible for its correctness.

List the fair market value (in U.S. dollars) of each class of assets and your U.S. adjusted basis (in U.S. dollars) in the class of assets. You can use good faith estimates of fair market value and basis. Formal appraisals are not required.

Subtract the amounts in column (b) from the amounts in column (a) and show the gain or (loss) in column (c). Enter negative amounts in parentheses.

If you are a former U.S. LTR, it may benefit you to complete column (d). For more details, see section 877(e)(3)(B). Only former U.S. LTRs should complete column (d).

Enter in column (d) the fair market value of each asset on the date you first became a U.S. resident for tax purposes.

List the appropriate amount in each column for all nonmarketable stock and securities issued by foreign corporations that would be controlled foreign corporations if you were still a U.S. citizen or resident. Note that these amounts are already included on line 5. Do not include amounts on this line in the total on line 20.

List the total value of all your partnership interests. If you hold an interest in one or more partnerships, you must attach a statement to Form 8854 that lists each partnership separately. Include the employer identification number (EIN), if any, for each partnership. Describe the assets and liabilities of each partnership (using the categories on the balance sheet on page 3 of Form 8854) attributable to your interest in the partnership.

List the total value of all assets held by trusts that you are considered to own for tax purposes. You must attach a statement to Form 8854 that lists each trust separately. Include the EIN (if any) for each trust. Describe the assets and liabilities of each trust (using the categories on the balance sheet on page 3 of Form 8854) attributable to your interest in the trust.

List the total value of all assets held by nongrantor trusts in which you are considered to have a beneficial interest. You must attach a statement to Form 8854 that lists each trust separately. Include the EIN (if any) for each trust. Describe the assets and liabilities of each trust (using the categories on the balance sheet on page 3 of Form 8854) attributable to your interest in the trust.

Intangible property includes any of the following items that have substantial value independent of the services of any individual.

Attach a statement describing and listing the total value of any other assets you have that are not included on lines 1 through 18.

Add lines 1 through 5 and 6 through 19, not including any amounts on line 5a. The amounts on line 5a are included in determining the amounts on line 5.

Attach a statement describing and listing the total value of any other liabilities you have that are not included on lines 21 and 22.

Most U.S. tax treaties do not prevent the United States from continuing to tax former citizens and former LTRs under domestic law. Unless the treaty prevents it, you will be subject to the rules of section 877.

Lines 3 through 6 require reporting of income which, but for the application of section 877(d), would be income from sources outside the United States. If you report income on these lines, you must also report this income as taxable income on Form 1040NR.

If you owned (within the meaning of section 958(a) or (b)) at any time during the 2-year period ending on the date of your expatriation or termination of residency, more than 50% of the vote or value of a foreign corporation, income or gain you receive from the foreign corporation during the tax year will be treated as from sources within the United States, to the extent such income or gain is not more than the earnings and profits from such stock which were earned or accumulated before the date of your expatriation or termination of residency while such ownership requirements were met.

If, during the current tax year, you exchanged any property, and (a) the gain would not (but for this paragraph) be recognized on such exchange in whole or in part, (b) income derived from such property was from sources within the United States (or, if no income was so derived, would have been from such sources), and (c) income derived from the property acquired in the exchange would be from sources outside the United States, then the property will be treated as sold for its fair market value on the date of the exchange, in accordance with Section V of Notice 97-19, 1997-1 C.B. 394. The removal of appreciated property with an aggregate fair market value in excess of $250,000, from the United States is an exchange of property covered by this provision.

Enter on line 5 the total amount of gain resulting from any such exchanges during the tax year, and if you have elected to enter into a gain recognition agreement with the IRS deferring the gain, attach a copy of the agreement to your Form 1040NR. If you dispose of any property covered by a gain recognition agreement during the tax year, also list the gain realized on this line. See Section V of Notice 97-19, for additional information on exchanges and gain recognition agreements.

If, during the 10-year period beginning on the date of your expatriation or termination of residency, or during the 5-year period prior to your expatriation or termination of residency, you contributed U.S. source property to a foreign corporation that would be a controlled foreign corporation had you remained a U.S. citizen or LTR, any income or gain on that property received or accrued by the foreign corporation during the tax year is treated as received or accrued by you. See Section VI of Notice 97-19 for additional information.

Add lines 1f through 7 to report your total income from U.S. sources.

List the total amount of all other income or gain for the tax year.

If you are subject to section 877 and required to file Form 8854 for any tax year, and you fail to file or do not include all the information required by the form or the form includes incorrect information, you will owe a penalty of $10,000 for that year, unless it is shown that such failure is due to reasonable cause and not willful neglect.