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OMB No. 1545-0074
Initial and Annual Expatriation Statement
Form 8854 For calendar year 2021 or other tax year beginning , 2021, and ending , 20
Department of the Treasury ▶ Go to www.irs.gov/Form8854 for instructions and the latest information . Attachment 2021
Internal Revenue Service ▶ Please print or type. Sequence No. 112
Name Identifying number (see instructions)

Part I General Information. For all filers.
1 Mailing address and telephone number where you can be reached after expatriation

2 Address of principal foreign residence (if different from line 1)

3 Country of tax residence (if different from line 2)

4 Check the box that applies. See instructions.

Initial expatriation statement for persons who expatriated in 2021. Complete Part II.
Annual expatriation statement for persons who expatriated before 2021. Complete Part III.

5 Date of expatriation under section 877A(g)(3) for expatriating citizens and long-term residents. See instructions.

Citizen
Long-term resident
Long-term resident with dual residency in a treaty country. Date commencing to be treated, for tax purposes, as a
resident of the treaty country

6 List all countries (including the United States) of which you are a citizen (see instructions).

a Name of country

b Date you became a citizen of each country listed in line 6a (see instructions).

7 How you became a U.S. citizen By birth By naturalization

8 Date you became a U.S. lawful permanent resident

Part II Initial Expatriation Statement for Persons Who Expatriated in 2021
Section A Expatriation Information
1 Enter your U.S. income tax liability (after foreign tax credits) for the 5 tax years ending before the date of your expatriation.
1st Year 2nd Year 3rd Year 4th Year 5th Year
Before Expatriation Before Expatriation Before Expatriation Before Expatriation Before Expatriation
$ $ $ $ $

2 Enter your net worth on the date of your expatriation for tax purposes . . . . . . . . . . $

3 Did you become at birth a U.S. citizen and a citizen of another country, and do you continue to be a citizen
of, and taxed as a resident of, that other country? . . . . . . . . . . . . . . . . . . . Yes No

4 If you answered “Yes” to question 3, have you been a resident of the United States for not more than 10 of
the last 15 tax years (including the year of your expatriation)? . . . . . . . . . . . . . . . . Yes No

5 Were you under age 181/2 on the date you expatriated and have you been a U.S. resident for not more than
10 tax years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

6 Do you certify under penalties of perjury that you have complied with all of your tax obligations for the 5
preceding tax years? See instructions . . . . . . . . . . . . . . . . . . . . . . . Yes No

For Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 24126N Form 8854 (2021)

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Form 8854 (2021)                                                                                                Page 2
Section B        Balance Sheet
List in U.S. dollars the fair market value and the U.S. adjusted basis of your assets and liabilities as of your expatriation date. For Lines 
6 and 7, list in U.S. dollars the present value of your pensions and deferred compensation interests as of your expatriation date. For 
more details, see the instructions.
                                   Assets                                   (a) Fair market  (b) U.S. adjusted  
                                                                            value (FMV)          basis
1   Cash, including bank deposits .    .   .   . . . . .   . . .
2   Marketable stock and securities issued by U.S. companies   .     
3   Marketable stock and securities issued by foreign companies
4   Nonmarketable stock and securities issued by U.S. companies  
5   Nonmarketable stock and securities issued by foreign companies
a   Separately state stock issued by foreign companies that would 
    be controlled foreign corporations if you were still a U.S. citizen 
    or permanent resident. See instructions .    . . . .   . . .
b   Provide the name, address, and EIN, if any, of  any such company
  
6   Pensions  or  similar  retirement  arrangements  (both  U.S.  and 
    foreign). See instructions .   . . .   .   . . . . .   . . .
7   Deferred compensation (including stock options). See instructions 
8   Partnership interests. See instructions    . . . . .   . . .
9   Assets held in trust. See instructions .   . . . . .   . . .
10  Beneficial interests in trusts not included in line 9. See instructions 
11  Intangibles used in the United States .    . . . . .   . . .
 12 Intangibles used outside the United States .   . . .   . . .
 13 Loans to U.S. persons .  .     . . .   .   . . . . .   . . .
14  Loans to foreign persons .     . . .   .   . . . . .   . . .
 15 Real property located in the United States .   . . .   . . .
 16 Real property located outside the United States .  .   . . .
17  Business property located in the United States.  . .   . . .
18  Business property located outside the United States.   . . .
19  Other assets. See instructions .   .   .   . . . . .   . . .
20  Total assets. Add lines 1 through 5 and lines 6 through 19. Don’t 
    include amounts on line 5a in this total .   . . . .   . . .
                                   Liabilities                              Amount
21  Installment obligations. .     . . .   .   . . . . .   . . .
22  Mortgages, etc.  . . .   .     . . .   .   . . . . .   . . .
23  Other liabilities. See instructions  . .   . . . . .   . . .
24  Total liabilities. Add lines 21 through 23 . . . . .   . . .
25  Net worth. Subtract line 24 from line 20, column (a) . . . .
                                                                                                 Form 8854 (2021)

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Form 8854 (2021)                                                                                                                           Page 3
Section C        Property Owned on Date of Expatriation
Don’t complete Section C if: 
      • Your average net income tax liability for the 5 tax years immediately before expatriation (see line 1 in Section A) wasn’t more 
         than  $172,000,  your  net  worth  on  the  date  of  your  expatriation  (see  line  2  in  Section  A)  was  under  $2  million,  and  you
         checked “Yes  ” on line 6 in Section A;
      • In Section A, you checked “Yes” on lines 3, 4, and 6; or
      • In Section A, you checked “Yes” on lines 5 and 6. 

1 a   Do you have any eligible deferred compensation items? Checking the “Yes” box is an irrevocable waiver 
      of any right to claim any reduction in withholding for such eligible deferred compensation item under any 
      treaty with the United States    .   . .  . .   .         . . . . .  .    . .   . .        . .    . . . . .  .    . .       Yes      No

b     Do  you  have  any ineligible  deferred  compensation  items?  If  “Yes,”  you  must  include  in  income  the
      present value of your account on the day before your expatriation date          . .        . .    . . . . .  .    . .       Yes      No

c     Do you have an interest in a   specified tax deferred accounts? If “Yes,” you must include in income the
      amount of your entire interest in the account on the day before your expatriation date              . . . .  .    . .       Yes      No

d     Are you a beneficiary of a nongrantor trust? See instructions        .    . .   . .        . .    . . . . .  .    . .       Yes      No

         Check this box to elect under section 877A(f)(4)(B) to be treated as having received the value of your entire interest in the 
         trust  (as  determined  for  purposes  of  section  877A)  as  of  the  day  before  your  expatriation  date.  Attach  a  copy  of  your 
         valuation letter ruling issued by the IRS. See instructions.

2     Recognition  of  gain  or  loss  on  the  deemed  sale  of  mark-to-market  property.Caution: Don’t  include  in  column  (a)  any 
      property described on line 1a, 1b, 1c, or 1d. 

Complete column (g) only if you are deferring tax on gain from any property listed in column (a).
                                                                                                   (e)  
          (a)                        (b)              (c)                  (d)            Gain after               (f)                 (g)  
Description of property      Fair market value   Cost or other        Gain or (loss).   allocation of the     Form or Schedule    Amount of tax 
                           on day before date         basis*          Subtract (c)    exclusion amount        on which gain       deferred (attach 
                             of expatriation                            from (b)        (see instructions)    or loss is reported computations)

3 Total. Add the amounts in column (d) and column (e)  .        . .
4  Total tax deferred. Add the amounts in column (g). Enter here 
   and on Part II, Section D, line 5 . .   . .  . .   .         . .
* You must identify as “(h)(2)” any property for which you are making the special basis election under section 877A(h)(2). This election is irrevocable. 
See the instructions for Part II, Section C, line 2, column (c).
                                                                                                                                  Form 8854 (2021)

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Form 8854 (2021) Page 4
Section D Deferral of Tax
Election to defer tax. You can defer tax only if you have provided adequate security. Adequate security is described
in the instructions.
1 Are you electing to defer tax under section 877A(b)?
Checking the “Yes” box is an irrevocable waiver of any right under any treaty of the United States
that would prevent assessment or collection of any tax imposed because of section 877A . . . . . . Yes No

If you checked the “Yes” box, continue to line 2. Otherwise, don’t complete lines 2 through 5.

2 Enter the total tax you would have reported, absent the deferral election, on Form 1040 or
1040-SR, line 24, for the part of the year including the day before the expatriation date absent the
deferral election . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Enter the total tax for the same part of the tax year determined without regard to the amounts
attributable to section 877A(a). Attach computation . . . . . . . . . . . . . . . . 3

4 Subtract line 3 from line 2. This is the amount of tax eligible for deferral . . . . . . . . 4

5 Enter the total tax deferred from Part II, Section C, line 4, column (g) . . . . . . . . . . 5

• If you are filing Form 1040 or 1040-SR, enter this amount in brackets to the left of the entry
space for line 24. Identify as “EXP.”

• If you are filing Form 1040-NR, enter this amount in brackets to the left of the entry space for line
24. Identify as “EXP.”
Part III Annual Expatriation Statement for Persons Who Expatriated Before 2021
• If you made an election to defer the payment of tax, complete line 1.
• If you have an item of eligible deferred compensation, complete line 2.
• If you are a beneficiary of a nongrantor trust, complete line 3.

1 Complete columns (a), (b), and (c) for all property on which you deferred tax on a prior year Form 8854. Complete column (d)
for any property you disposed of in 2021 and see the instructions for Part III.
(a) (b) (c) (d)
Description of property Amount of mark-to-market gain or Amount of tax deferred on prior year Date of disposition (if any)
(loss) reported on prior year Form 8854
Form 8854

Form 8854 (2021)

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Form 8854 (2021)                                                                                                              Page  5 
Part III Annual Expatriation Statement for Persons Who Expatriated Before 2021 (continued)
2    Did you receive any distributions of eligible deferred compensation items for 2021?  . .   . . . . . .              Yes  No
     If “Yes,” enter the amount of distribution(s) and amount withheld at source, if any, below.

                 Amount of distribution     Amount withheld at source, if any
     1
     2
     3

3    Did you receive any distributions from a nongrantor trust for 2021? .   . . . . .   .  .   . . . . . .              Yes  No
     If “Yes,” enter the amount of distribution(s) and amount withheld at source, if any, below.

                 Amount of distribution     Amount withheld at source, if any
     1
     2
     3

                 Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the 
                 best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than filer) is based on all information 
                 of which preparer has any knowledge.
Sign Here
                 Your signature                                                      Date

                 Print/Type preparer’s name          Preparer’s signature              Date                              PTIN
Paid                                                                                                  Check          if  
                                                                                                      self-employed 
Preparer                         ▶                                                                    Firm’s EIN ▶
                 Firm’s name     
                 Firm’s address 
Use Only         ▶                                                                                    Phone no. 
                                                                                                                         Form 8854 (2021)

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