Form 2063                                 U.S. Departing Alien Income Tax Statement                                                                                    Annual Certificate of Compliance 
                                                                                                                                                                                        (IRS Form 2063) 
(Rev. September 2024)                                                                                                               OMB No. 1545-0138 
                               For a Resident Alien Against Whom a Termination Assessment Has Not Been Made or     
Department of the Treasury      for a Nonresident Alien Having No Taxable Income From United States Sources 
Internal Revenue Service                        Go to www.irs.gov/Form2063 for the latest information.                                                              This certifies that 
1   Name (please print or type)                                                                                           Social security number or ITIN, if any 
                                                                                                                                                                    has satisfied all United States of America income tax obliga- 
2   U.S. address (number, street, apt. no. or rural route, city, state, and ZIP code)                                                                               tions with respect to income received or to be received for 
                                                                                                                                                                    the tax year ended                           ,                , 
                                                                                                                                                                    determined to the extent practicable, based on all information  
                                                                                                                                                                    available to me on this date. 
3   Foreign address (street address, city or town, state or province, country, and ZIP or foreign postal code)                                                      
                                                                                                                                                                       (Field Assistance Area Director)   
                                                                                                                                                                                        Internal Revenue Service 

4  Tax year                 5   While in the U.S., check if you were:    6  Of what country are you a citizen or subject? 7  Passport or alien registration         By 
                                An employee                                                                                   card number                                               (Name and title) 
                                Self-employed  
8  Date of departure        9  Original date of your entry into the U.S. 10  Date on which you last arrived in the U.S. (MM/DD/YYYY)
   (MM/DD/YYYY)                (MM/DD/YYYY)

11   Are you a resident alien                                                                                                                                                           Area Director’s Stamp 
     of the U.S.?                    Yes             No     If “No,” enter the country of which you are a resident 

                                                                         Cat. No. 21420Y                                                                            For Privacy Act and Paperwork Reduction Act Notice, see back of form. 

12a   Did you receive or do you expect to receive any income subject to U.S. income tax for the tax year shown on                                                                                   IMPORTANT 
      line 4 on the front of this form? If “Yes,” complete 12b and 12c. If “No,” go to line 13  . . . . .  . .        Yes    No                                                                 Please keep this certificate  
b     Was U.S. income tax withheld?     . .  .   . .    .   .   . .  .     . .    . . .  .        . . . .  . .        Yes    No                                                                     with your passport 
c     Did you make any estimated income tax payments?       .   . .  .     . .    . . .  .        . . . .  . .        Yes    No
                                                                                                                                                         Privacy Act and Paperwork Reduction Act Notice. We ask for the  
                                                                                                                                                         information on this form to carry out the Internal Revenue laws of the 
13a   Did you receive any income subject to U.S. income tax during theprior tax year? If “Yes,” complete 13b and                                         United States. Internal Revenue Code sections 6001, 6011, 6012(a), 6109, 
                                                                                                                                                         and 6851, and their regulations require that you give us the information, 
      13c. If “No,” go to line 14   . . . .  .   . .    .   .   . .  .     . .    . . .  .        . . . .  . .        Yes    No                          including your identifying number(s). Routine uses of this information 
b     U.S. address shown on the income tax return you filed for that year:                                                                               include giving it to the Department of Justice for civil and criminal litigation 
                                                                                                                                                         and to cities, states, the District of Columbia, and U.S. commonwealths or 
                                                                                                                                                         territories to carry out their tax laws. We may also disclose this information 
                                                                                                                                                         to other countries under a tax treaty, to federal and state agencies to 
                                                                                                                                                         enforce federal nontax criminal laws, or to federal law enforcement and 
                                                                                                                                                         intelligence agencies to combat terrorism. If you do not give us the 
                                                                                                                                                         information asked for, or provide false or incomplete information, you may 
c    (1) Year             (2) Taxable income                         (3) Tax paid                            (4) Balance due                             be subject to penalties.
                                                                                                                                                         You are not required to provide the information requested on a form that 
                                                                                                                                                         is subject to the Paperwork Reduction Act unless the form displays a valid 
                                                                                                                                                         OMB control number. Books or records relating to a form or its 
                                                                                                                                                         instructions must be retained as long as their contents may become 
14    Are you liable for filing tax returns or paying taxes to the United States for any prior year not shown above?  Yes    No                          material in the administration of any Internal Revenue law. Generally, tax 
                                                                                                                                                         returns and return information are confidential, as required by Code 
Declaration. Under penalties of perjury, I declare that I have examined the above statements, and to the best of my knowledge and belief, they are true, section 6103. 
             correct, and complete.                                                                                                                      The time needed to complete and file this form will vary depending on 
                                                                                                                                                         individual circumstances. The estimated average time is: Recordkeeping, 
                                                                                                                                                         6 min.; Learning about the law or the form, 3 min.; Preparing the form, 
Sign                                                                                                                                                     26 min.; Copying, assembling, and sending the form to the IRS, 13 min. 
Here                                                                                                                                                     If you have comments concerning the accuracy of these time estimates or 
      Signature of departing alien                                                                    Date                                               suggestions for making this form simpler, we would be happy to hear from 
                                                                                                                                                         you. You can send us comments through www.irs.gov/FormComments, or 
                                                                                                                                                         you can write to the Internal Revenue Service, Tax Forms and 
                                                                                                                                                         Publications, 1111 Constitution Ave. NW, IR-6526, Washington, DC 
                                                                                                                                                         20224. Don’t send your tax return or this form to this address.