Form  2063                                U.S. Departing Alien Income Tax Statement                                                                                    Annual Certificate of Compliance 
                                                                                                                                                                                        (IRS Form 2063) 
(Rev. September 2013)       For a Resident Alien Against Whom a Termination Assessment Has Not Been Made or                         OMB No. 1545-0138 
Department of the Treasury      for a Nonresident Alien Having No Taxable Income From United States Sources 
Internal Revenue Service                ▶ Information about Form 2063 is available at www.irs.gov/form2063.                                                         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

13a   Did you receive any income subject to U.S. income tax during theprior tax year? If “Yes,” complete                                                 Privacy Act and Paperwork Reduction Act Notice.We ask for the         information on 
                                                                                                                                                         this form to carry out the Internal Revenue laws of the United        States. Internal 
      13b and 13c  .  .   .         . .   . . . . . .   .   .   . .  .     . . .  .   .  .      . . . .  . .   .        Yes No                           Revenue Code sections 6001, 6011, 6012(a), 6109, and 6851,            and  their regulations 
                                                                                                                                                         require  that  you  give  us  the  information,  including  your  identifying  number(s). 
b     U.S. address shown on the income tax return you filed for that year:                                                                               Routine uses of  this information 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 possessions 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 
c    (1) Year             (2) Taxable income                         (3) Tax paid                          (4) Balance due                               asked  for,  or  provide  false  or  incomplete  information,  you  may  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  
14    Are you liable for filing tax returns or paying taxes to the United States for any prior year not shown above?  . Yes No                           must  be  retained  as  long  as  their  contents  may  become  material  in  the  
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, administration  of  any  Internal  Revenue  law.  Generally,  tax  returns  and  
                                                                                                                                                         return information are confidential, as required by Code 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 
Sign  ▲                                                                                                                                                  about  the  law  or  the  form,  3  min.; Preparing  the  form,  26  min.; Copying, 
                                                                                                                                                         assembling, and sending the form to the IRS, 13 min. If you have comments 
Here                                                                                                                                                     concerning the accuracy of these time estimates or suggestions for making this 
             Signature of departing alien                                                           Date                                                 form simpler, we would be happy to hear from you. You can send us comments 
                                                                                                                                                         from www.irs.gov/formspubs/. Click on “More Information” and then on “Comment 
                                                                                                                                                         on Tax Forms and Publications.” You can write to the Internal Revenue Service, 
                                                                                                                                                         Tax  Forms  and  Publications,  SE:W:CAR:MP:TFP,  1111  Constitution  Ave.  NW, 
                                                                                                                                                         IR-6526, Washington, DC 20224. Do not     send your tax return or this form to this 
                                                                                                                                                         address.