Form 8802 (Rev. April 2012) F8802
User Manual: 8802
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Form 8802 Application for United States Residency Certification (Rev. April 2012) Department of the Treasury Internal Revenue Service ▶ OMB No. 1545-1817 See separate instructions. Important. For applications filed after March 31, 2012, the user fee is $85 per application. Additional request (see instructions) Electronic payment confirmation no. For IRS use only: Pmt Amt $ Foreign claim form attached ▶ / / 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 . Deposit Date: ▶ 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 ▶ Phone No. ▶ ( 4 a b c d e f g h i j ) CAF No. ▶ Fax No. ▶ ( ) Applicant is (check appropriate box(es)): 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) ▶ to ▶ Dual-status U.S. resident (see instructions). From ▶ to ▶ Partial-year Form 2555 filer (see instructions). U.S. resident from ▶ Partnership. Check all applicable boxes. U.S. Foreign LLC Trust. Check if: Grantor (U.S.) IRA (for Individual) Simple Rev. Rul. 81-100 Trust Grantor (foreign) Complex Section 584 IRA (for Financial Institution) Estate 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. S corporation Employee benefit plan/trust. Plan number, if applicable ▶ Check if: Section 401(a) Section 403(b) Section 457(b) 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) ▶ Disregarded entity. Check if: LLC LP LLP Other (specify) ▶ 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) Page 2 Form 8802 (Rev. 4-2012) 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 Other (specify) ▶ No. 6 Attach explanation (see instructions). Check applicable box and go to line 6. Minor child QSub U.S. DRE Foreign DRE FASIT Foreign partnership Other ▶ 5227 5500 Section 761(a) election 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 Other (specify) ▶ Parent’s/owner’s name and address ▶ 1120 1120S 5500 7 and U.S. taxpayer identification number ▶ No. Attach explanation (see instructions). 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 here 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 only for obtaining information or assistance from that person relating to matters designated on line 9. Applicant’s daytime phone no.: Applicant’s signature (or individual authorized to sign for the applicant) Keep a copy for your records. ▶ Signature Date 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) Page 3 Worksheet for U.S. Residency Certification Application Form 8802 (Rev. 4-2012) 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 12 Enter the total number of certifications requested (add columns A, B, C, and D of line 11) . # Column D - Total . . . . . . . . . ▶ Form 8802 (Rev. 4-2012)
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