Application for United States  
Form 8802
                                                 Residency Certification
(Rev. November 2018)                                                                                                         OMB No. 1545-1817
Department of the Treasury                          ▶ See separate instructions.
Internal Revenue Service
Important. For applicable user fee information, see the Instructions for Form 8802.                                      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. 11-2018)

Form 8802 (Rev. 11-2018)                                                                                                           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. 11-2018)

Form 8802 (Rev. 11-2018)        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 allyears 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. 11-2018)