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Application for United States
Form 8802
Residency Certification
(Rev. April 2012) OMB No. 1545-1817
Department of the Treasury ▶ See separate instructions.
Internal Revenue Service
Important. For applications filed after March 31, 2012, the user fee is $85 per application. For IRS use only:
Pmt Amt $ .
Additional request (see instructions) Foreign claim form attached Deposit Date: / /
Electronic payment confirmation no. ▶ Date Pmt Vrfd: / /
Applicant’s name Applicant’s U.S. taxpayer identification number

If a joint return was filed, spouse’s name (see instructions) If a joint return was filed, spouse’s U.S. taxpayer
identification number

If a separate certification is needed for spouse, check here ▶
1 Applicant’s name and taxpayer identification number as it should appear on the certification if different from above

2 Applicant’s address during the calendar year for which certification is requested, including country and ZIP or postal code. If a P.O.
box, see instructions.

3a Mail Form 6166 to the following address:

b Appointee Information (see instructions):
Appointee Name ▶ CAF No. ▶
Phone No. ▶ ( ) Fax No. ▶ ( )

4 Applicant is (check appropriate box(es)):
a Individual. Check all applicable boxes.
U.S. citizen U.S. lawful permanent resident (green card holder) Sole proprietor
Other U.S. resident alien. Type of entry visa ▶
Current nonimmigrant status ▶ and date of change (see instructions) ▶
Dual-status U.S. resident (see instructions). From © to ▶
Partial-year Form 2555 filer (see instructions). U.S. resident from ▶ to ▶
b Partnership. Check all applicable boxes. U.S. Foreign LLC
c Trust. Check if: Grantor (U.S.) Simple Rev. Rul. 81-100 Trust IRA (for Individual)
Grantor (foreign) Complex Section 584 IRA (for Financial Institution)
d Estate
e Corporation. If incorporated in the United States only, go to line 5. Otherwise, continue.
Check if: Section 269B Section 943(e)(1) Section 953(d) Section 1504(d)
Country or countries of incorporation ▶
If a dual-resident corporation, specify other country of residence ▶
If included on a consolidated return, attach page 1 of Form 1120 and Form 851.
f S corporation
g Employee benefit plan/trust. Plan number, if applicable ▶
Check if: Section 401(a) Section 403(b) Section 457(b)
h Exempt organization. If organized in the United States, check all applicable boxes.
Section 501(c) Section 501(c)(3) Governmental entity
Indian tribe Other (specify) ▶
i Disregarded entity. Check if: LLC LP LLP Other (specify) ▶
j Nominee applicant (must specify the type of entity/individual for whom the nominee is acting) ▶
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 10003D Form 8802 (Rev. 4-2012)

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Form 8802 (Rev. 4-2012) Page 2
Applicant name:
5 Was the applicant required to file a U.S. tax form for the tax period(s) on which certification will be based?
Yes. Check the appropriate box for the form filed and go to line 7.
990 990-T 1040 1041 1065 1120 1120S 3520-A 5227 5500
Other (specify) ▶

No. Attach explanation (see instructions). Check applicable box and go to line 6.
Minor child QSub U.S. DRE Foreign DRE Section 761(a) election
FASIT Foreign partnership Other ▶

6 Was the applicant’s parent, parent organization or owner required to file a U.S. tax form? (Complete this line only if you checked
“No” on line 5.)
Yes. Check the appropriate box for the form filed by the parent.
990 990-T 1040 1041 1065 1120 1120S 5500
Other (specify) ▶
Parent’s/owner’s name and address ▶

and U.S. taxpayer identification number ▶
No. Attach explanation (see instructions).
7 Calendar year(s) for which certification is requested.
Note. If certification is for the current calendar year or a year for which a tax return is not yet required to be filed, a penalties
of perjury statement from Table 2 of the instructions must be entered on line 10 or attached to Form 8802 (see instructions).

8 Tax period(s) on which certification will be based (see instructions).

9 Purpose of certification. Must check applicable box (see instructions).
Income tax VAT (specify NAICS codes) ▶
Other (must specify) ▶

10 Enter penalties of perjury statements and any additional required information here (see instructions).

Sign Under penalties of perjury, I declare that I have examined this application and accompanying attachments, and to the best of my knowledge and belief,
they are true, correct, and complete. If I have designated a third party to receive the residency certification(s), I declare that the certification(s) will be used
here only for obtaining information or assistance from that person relating to matters designated on line 9.

Applicant’s signature (or individual authorized to sign for the applicant) Applicant’s daytime phone no.:
Keep a
copy for
your Signature Date
records. ©
Name and title (print or type)

Spouse’s signature. If a joint application, both must sign.

Name (print or type)
Form 8802 (Rev. 4-2012)

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Form 8802 (Rev. 4-2012)         Worksheet for U.S. Residency Certification Application                                                   Page 3
Applicant Name                                                                     Applicant TIN

Appointee Name (If Applicable)

Calendar year(s) for which certification is requested (must be the same year(s) indicated on line 7)

11 Enter the number of certifications needed in the column to the right of each country for which certification is requested.
Note. If you are requesting certifications for more than one calendar year per country, enter the total number of certifications for all years for 
each country (see instructions).
          Column A                             Column B                           Column C                            Column D
   Country       CC           # Country                  CC  #             Country                  CC #         Country         CC      #

Armenia                 AM      Finland                  FI           Latvia                        LG     South Africa          SF

Australia               AS      France                   FR           Lithuania                     LH     Spain                 SP

Austria                 AU      Georgia                  GG           Luxembourg                    LU     Sri Lanka             CE

Azerbaijan              AJ      Germany                  GM           Mexico                        MX     Sweden                SW

Bangladesh              BG      Greece                   GR           Moldova                       MD     Switzerland           SZ

Barbados                BB      Hungary                  HU           Morocco                       MO     Tajikistan                TI

Belarus                 BO      Iceland                  IC           Netherlands                   NL     Thailand              TH

Belgium                 BE      India                    IN           New Zealand                   NZ     Trinidad and Tobago   TD

Bermuda                 BD      Indonesia                ID           Norway                        NO     Tunisia               TS

Bulgaria                BU      Ireland                  EI           Pakistan                      PK     Turkey                TU

Canada                  CA      Israel                   IS           Philippines                   RP     Turkmenistan          TX

China                   CH      Italy                    IT           Poland                        PL     Ukraine               UP

Cyprus                  CY      Jamaica                  JM           Portugal                      PO     United Kingdom        UK

Czech Republic          EZ      Japan                    JA           Romania                       RO     Uzbekistan            UZ

Denmark                 DA      Kazakhstan               KZ           Russia                        RS     Venezuela             VE

Egypt                   EG      Korea, South             KS           Slovak Republic               LO

Estonia                 EN      Kyrgyzstan               KG           Slovenia                      SI

Column A - Total                Column B - Total                           Column C - Total                    Column D - Total 

12 Enter the total number of certifications requested (add columns A, B, C, and D of line 11)  .         . .   .  . .   . .  .   .   ▶

                                                                                                                        Form 8802 (Rev. 4-2012)

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